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 numbers to send applicable records for:

Inpatient Rehabilitation — 801-581-6662

Sugarhouse Outpatient Rehabiliation Therapy — 801-581-2043

Physical Medicine & Rehabilitation Outpatient Physician/Wheelchair Evaluations/Spasticity Management — 801-585-3498

Office hours: 8 am–5 pm

Referring Provider Information

Full Name (Last, First)*:

Email Address*:

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: