Refer a Patient to Pediatric Services

Consultation & Referral Services

Pediatrics is here to assist community physicians and specialists with consultation and referral services. To refer a patient, please complete the form below and fax all related clinic notes and diagnostic reports to the specialty fax number.

If no fax or online referral form is listed, you will need to call the service directly.

Contact & Fax Information

General Fax: 801-587-7539
Prescription Refills Fax: 801-213-7600

Adolescent Medicine
Cardiology
Complex Care Endocrinology
GI/Gastroenterology
Genetics
Nephrology
Pulmonary/Sleep Medicine
Rheumatology

Specific Specialty Contact Information

PM&R (Physical Medicine & Rehabilitation)

Phone: 801-662-5888
Referral information (do not use form below)

Referring Provider Name: ^*

Referring Office Phone Number: ^*

Referring Provider Email:

Referring Office Fax Number:

Referring Provider Npi Number:

Type Of Consult: ^*

Preliminary Diagnosis: ^*

Specialty You Are Referring To

Reason For Referral: ^*

Patient Information

Name: ^*

Date Of Birth: ^*

Phone: ^*

Street: ^*

City: ^*

State: ^*

ZIP: ^*