Provider Referral Form - IV/IM
For providers in the community that would like to refer their patient to the MIMC IV room. Pick from our menu of IV/IM options or customize your own formula. Note: if you do not have prescribing authority in the state of MN, customized IV/IM options will require your patient have a brief consult with our nurse practitioner at addition cost.
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Your name + credentials *
Patient Name: *
Patient DOB: *
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Patient Phone Number: *
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