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Public Health Nursing Referral

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To begin, click “Start” for the Referral Source information page.
Click “Next” for second and third pages, Client Information and Client's medical provider information.
Click “Next” again for a summary which you can print or save as a PDF for your records.
Click “Next” again. You will see "Preparing Document," click the agree statement and “Continue” button and sign the referral. (Your signature is only to make the process work; you may print or download the form at this point, too).
Click “Finish” and you will see a thank you message that means the referral has been submitted securely to us at publichealth@bloomingtonmn.gov.

Include detailed information about the reason for the nurse visit. A more complete form will help us better meet an individual’s needs.
Email or fax a discharge summary or other relevant medical information as appropriate, along with the completed referral form. (Bloomington Public Health does not have access to Epic or any other external electronic medical records.)
For parent/baby (postpartum/newborn) referrals, please put parent at the top of the form and put baby under other family members. Include baby’s date of birth and relationship (son, daughter) to the parent.

Questions? Contact Public Health at 952-563-8900 or publichealth@BloomingtonMN.gov.

Thank you for your help in protecting the health of our community.

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952-563-8900

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