Refer A Patient—Plastic Surgery

Now Taking Physician Referrals

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

Thank you for contacting plastic surgery services at University of Utah Health. To refer your patient, please fill out the form below and click on the button labeled "Submit." We will respond to you within 24-48 hours.

Referring Physician Information

Referring Provider Full Name: ^*

Referring Office Contact: ^*

Department (If Applicable): ^*

Referring Phone Number: ^*

Referring Provider Fax: ^*

Referring Provider Email Address: ^*

Referring Provider Npi Number: ^*

Type Of Physician: ^*

Referring To ^*

Reason For Referral: ^*

Patient Information

First Name: ^*

Last Name: ^*

Date Of Birth:

Patient's Gender: ^*

If You Selected 'Other' For Patient Gender Please Specify How The Patient Identifies:

Address:

City:

State:

ZIP:

Phone: ^*

Secondary Phone:

University Of Utah Health Medical Record Number:

Insurance Information

Primary Insurance Policy Number: ^*

Policy Holder: ^*

Phone Number: ^*

Insurance Provider: ^*

Secondary Insurance

Policy Number: ^*

Policy Holder: ^*

Phone Number: ^*

Insurance Provider: ^*