Refer a Patient to General Surgery

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.

If you are trying to reach colorectal, here is the fax number: FAX 801-585-1520

Referring Provider Information

Referring Provider Name ^*

Referring Provider Email Address ^*

Referring Provider Phone Number ^*

Referring Provider Fax Number

Referring Provider NPI Number ^*

Type of Consult ^*

Preliminary Diagnosis ^*

Reason for Referral ^*

Patient Information

First Name ^*

Last Name ^*

Date of Birth ^*

Patient's Gender

Male

Female

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Please Specify How the Patient Identifies

Phone Number ^*

Address

City

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ZIP/Postal Code