Refer a Patient

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: 801-581-4404

Office hours: 8 am–5 pm

Referring Provider Information

Full Name (Last, First)*:

Office Phone Number*:

Office Fax Number:

Office Address*:

Office/Clinic Name:

Referring to Information

Would you like to request a specific 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

Full Name (Last, First, Middle/Initial)*:

Date of Birth*:

Full Name of Parent or Guardian (If Minor) (Last, First):

Gender*:

*If you selected "Other" for patient gender, please specify how the patient identifies:

Phone*:

Address*:

City*:

State*:

ZIP Code*:

If interpreter is needed, please specify language:

Insurance: