Refer a Patient

Thank you for contacting Dermatology Services at University of Utah Health. We value our relationship with referring physicians.

To refer a patient, please fill out your patient's personal information below and click on the button labeled "Submit".

Name (Last, First)*:

Office Phone Number*:

Office Fax Number*:

Office Address*:

Office Zip Code*:

Clinic Name:

Referring to (specific doctor):

Department (What department would you like to refer your patient to?):

Full Name (Last, First, Middle or initial)*:

Date of Birth*:

Name of parent or guardian if minor (Last, First):

Sex*:

Male Female Other

If "Other" please explain:

Phone*:

Address*:

City*:

State*:

Zip Code*:

Preferred language*:

Interpreter Needed*:

No Yes

Insurance*:

Preliminary Diagnosis*:

Reason for Referral *:

Urgency Rating*:

Or Call 801-581-2955