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Now Taking Physician Referrals

Complete the web form below to refer a patient. You will receive an email confirmation from our team to confirm your receipt. We will also ask you to share additional patient information. 

If you prefer, you can fax your referral to 801-585-5091. 

Referring Provider Information
Patient Information

Patient Information Needed

The following information, if available, will be requested at the time of referral:

  • Patient demographics, including current insurance information
  • Two years of medical records from all attending physicians and specialists
  • History and physical
  • Lab work
  • Radiology reports
  • Pathology report, including liver biopsy if available
  • Surgery and procedure reports, including EGD, Colonoscopy, pap smear, and mammogram, if applicable
  • If there is a history of drug or alcohol abuse, the patient will need to provide documentation of six months of attendance in a relapse prevention program, such as alcoholics anonymous, or private inpatient or outpatient treatment and results of six months of random drug and alcohol screens from referring physicians.
  • Immunization records
  • A letter from your dentist stating that all dental work has been completed and that no further dental treatment, other than teeth cleaning, should be required for one year.