Refer a Patient to Pediatric Surgery

Now Taking Physician Referrals

Learn more about patient safety precautions, virtual visit options, and referring physician resources.

Thank you for referring your pediatric patient to University of Utah Health. Please fill out the form below and click on the button labeled "Submit." We will respond to you within 1-2 business days.

Referring Provider Name: ^*

Referring Office Phone Number: ^*

Referring Provider Email: ^*

Referring Office Fax Number:

Referring Provider Npi Number: ^*

Type Of Consult ^*

Preliminary Diagnosis ^*

Reason For Referral ^*

Patient Information

Name ^*

Date Of Birth ^*

Phone ^*

Street: ^*

City: ^*

State: ^*

ZIP: ^*

Call 801-662-2950 or