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Refer a Patient

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  Robert M. Roach, M.D.
  Hart P. Garner, M.D.
  Kyle M. Uittenbogaard, M.D.
  Kyle S. Nelson, M.D.
  Timothy J. Kovanda, M.D.
  Joseph R. Kapurch, M.D.
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  Krista M. Skoglund, PA-C
  Kayla M. Heyn, PA-C
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Refer a Patient

Home/Refer a Patient

Refer a PatientDSI Support2019-11-01T06:44:55-06:00

You may fill out the form below and submit electronically. Alternatively, you may also download and print this document, and then fax it to 763-427-4643.

Refer a Patient

UrgentNon-urgent

If this is an emergency, please call our office: 763-427-1137

Patient:

Date:

Date of Birth:

Phone number to contact patient:

Primary Concern/Diagnosis:

Referring Clinic Name:

Referring Physicians/Referral Coordinator:

Phone Number:

Has the patient had recent imaging?YesNo

Where was imaging done?

Date:

Referred to:1st AvailableRoachGarnerUittenboggardNelsonKovanda

Clinic location preference:Coon RapidsMinneapolisPlymouthRobbinsdaleMaple GroveChaska

Or Fax this form to: 763-427-4643

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Coon Rapids Office (Main)

11850 Blackfoot Street NW Suite 490
Coon Rapids, MN 55433 ^{Map it}

Phone: (763) 427-1137

Other Locations

West Health Office ^{Map It}
North Memorial Office ^{Map It}
Abbott Office ^{Map It}
Chaska Office ^{Map It}
Maple Grove Office ^{Map It}

Voted Top Doctors by MSP Magazine

American Board of Neurological Surgery Certified

American Board of Neurological Surgeons Certified

Hospital Affiliations

Abbott Northwestern Hospital
North Memorial Hospital
Mercy Hospital
Fairview University Medical Center

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