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. Fax applicable records to: 801-587-3997 Office hours: 8 am–5 pm You must have JavaScript enabled to use this form. Referring Provider Information Provider Full Name (Last, First): * Office Phone Number: * Office Fax Number: Office Address: * Office/Clinic Name: Referring to Information Name of Requested Provider: Specialty Department You Are Referring the Patient to: * Preliminary Diagnosis: * Reason for Referral: * Urgency Rating: Urgent 24-hour contact Routine 48 hour Patient Information Patient Full Name (Last, First): * Full Name Of Parent Or Guardian (If Minor): Date Of Birth: * Gender: Gender: * - Select -FemaleMalePrefer Not to AnswerOther… Enter other… Phone Number: * Address: Address: * City: * State: * - Select -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: * If Interpreter Is Needed, Please Specify Language: Insurance: Leave this field blank
