Clinical Neurosciences Center

Referring Physician Information

The Clinical Neurosciences Center is here to assist community physicians and specialists with consultation and referral services. To refer a patient, please complete our online physician referral form and fax all related clinic notes and diagnostic reports to 801-585-2746.

Once the form is completed, you will receive a return email confirming your referral and providing you with a referral tracking number in case you would like to follow-up or provide additional information at a later time. The information submitted will be reviewed within 48 hours to ensure that the proper neurologist or neurosurgeon evaluates each case, and the patient will be contacted about an appointment.

For MEG referrals, please fill out this form and fax it to 801-585-2746.

For EMG referrals, please fill out this form and fax it to 801-581-8859.
If you have any questions, please call the Neurosciences Referral Line at 801-585-7575.

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Physician Information:

Patient Information

Has the patient had any of the following?

Insurance Information

Primary Insurance

Secondary Insurance