You must have JavaScript enabled to use this form. Now Taking Physician Referrals Learn more about patient safety precautions, virtual visit options, and referring physician resources. To refer your patient, please fill out the form below and click on the button labeled "Submit". Referring Provider Name: * Referring Office Contact: * Referring Provider Phone: Referring Provider Fax: Referring Provider Email Address: Referring Provider Npi Number: * Physician - None -University of Utah Health PhysicianCommunity Physician Patient Name: Patient Phone: University Of Utah Health Medical Record Number (If Known): Date of Birth: basic info Address: City: State: - 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 Code: Symptoms To Be Addressed: Leave this field blank
