Refer a Patient to Mayo Clinic

Use this form to do a referral request not to perform an eConsult request. The following information will be sent to our Request Coordinator for processing. Please include all information to expedite the process.

* = required field

Please provide the following Referral Request Information

Patient Information


Pediatric patients (<18 years of age) require parent/guardian name and phone number.

Please provide the following Referral Request Information

Supporting Clinical Information
Be specific on what you want to send to Mayo for your referral. Tell us as much about the testing and data you want sent including; performing entities/locations, dates, and if you have the information in your office Electronic Health Record or if we need to get from the performing entity. Check the applicable boxes below and identify the patient medical information pertinent to their continued care.


We need your office to fax all results/reports from your EMR that you want sent to Mayo to:
Fax: 319-368-5581
Attention: Janet Libe

Cardiac results