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. You must have JavaScript enabled to use this form. Referring Provider Information Referring Provider Name * Referring Office Phone Number * Referring Provider Fax Number Referring Provider NPI Number * Type of Consult * Would You Like to Request a Specific Provider? No Yes Please provide the name of the provider Preliminary Diagnosis * Reason for Referral * Patient Information Name First Name Last Name Date of Birth * Phone Number * Address Address City/Town ZIP/Postal Code Leave this field blank
