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 referring your patient to University of Utah Health. We value our relationship with referring physicians. Please fill out the form below or submit your request through the U of U Health MedPic app.

Fax applicable records to 801-581-7719

Office Hours: Monday to Friday 8 a.m. – 5 p.m.

If this is an urgent request, please call 801-581-7719 during office hours or 801-581-2121 outside of office hours.

Referring Physician Information

Referring Provider Full Name: ^*

Referring Office Contact: ^*

Referring Phone Number: ^*

Referring Provider Fax: ^*

Referring Provider Email Address: ^*

Type Of Physician: ^*

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: ^*