Refer a Patient to the Endoscopic Spine & Percutaneous Spine Program

Now Taking Physician Referrals & Consultations

Our specialists are here to assist community physicians and specialists with consultation and referral services. We will promptly review the information you submit to ensure that the proper endoscopic or percutaneous spine specialist evaluates each case. Once we receive your referral, we will contact your patient to schedule an appointment.

How to Refer a Patient to University of Utah Health

Complete our online physician referral form below.
Fax all related clinic notes and diagnostic reports to us at 801-581-4404.
After you submit the form, you will receive a confirmation email with a referral tracking number. You may use your referral tracking number to follow-up or provide additional information at a later time.

Explore Virtual Visit Options & Referring Physician Resources

Referring Physician Information

Referring Provider Full Name

Referring Office Contact

Department (If Applicable)

Referring Provider Email Address

Referring Provider NPI Number

Type of Provider

Urgency Rating

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/Town

State/Province

ZIP/Postal Code

Phone

Secondary Phone

University of Utah Health Medical Record Number

Spine Symptoms/Conditions To Be Addressed

What type of care are you referring the patient for?

Surgical

Non-surgical

Has the patient had an MRI?

Yes

Please provide the MRI date if applicable

Has the patient had a CT scan?

Yes

Please provide the CT scan date if applicable

Has the patient had any X-rays?

Yes

Please provide the X-ray date if applicable

Insurance Information

Insurance Policy Number

Policy Holder

Phone Number

Insurance Provider