12500 Willowbrook Road
Cumberland, Maryland 21502


Outpatient Diagnostic Order Forms and Referrals

This section of the WMHS web site is reserved for physician practices and WMHS partners, for the purpose of providing down-loadable copies of the order forms and referrals needed for Outpatient Diagnostic Services at the Western Maryland Health System.

Please click on the link below for the pdf of each form:

Cardiology Order form

Center for Diabetes Management (Referral form)
Diabetes Self Management Training (DSMT) Referral form

General Radiology Order form

Interventional Orders form

Laboratory Requisition forms
Allergen Requisition
General Lab Requisition
Microbiology Requisition
Physician Order Form
Pre-Admission Testing Form
Prenatal-OB GYN Form

Mammography Order form

MRI Order form

Nuclear Order form

Outpatient Anticoagulation Clinic Forms
New Patient Referral Form
Continuation of Care Referral Form

PET-CT Order form
Physician Office Guide for CT Procedures
Patient Instructions for CT Procedures
Post-Procedure Instructions for Out-Patients taking Metformin or Glucophage

Referral forms for Registered Dietitian

Wound Care Center New Referral form

For questions or additional forms, please call Kelly Borsuk, Physician Liaison at WMHS, at 240-964-8020.  You can also reach her by e-mail at kborsuk@wmhs.com.

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