Now Taking Physician Referrals Learn more about patient safety precautions, virtual visit options, and referring physician resources. Thank you for referring your patient to University of Utah Health. We value our relationship with referring physicians. Please fill out the form below. Referral Form You must have JavaScript enabled to use this form. Referring Provider Name Referring Provider Phone Number Referring Provider Fax Number Referring Provider Email Address Referring Provider NPI Number Type of Consult Preliminary Diagnosis Reason for Referral Patient Information First Name Last Name Date of Birth Phone Number Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Leave this field blank
