Refer a Patient, Weight Loss Management Program

Now Taking Physician Referrals

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

Thank you for referring your patient to the Weight Management Program at University of Utah Health. Please fill out the form below. Then, click on the button labeled "submit."

Referring Provider Name*:

Referring Office Phone Number*:

Referring Office Fax Number :

Referring Provider Email:

Referring Provider NPI Number*:

Type of Consult*:

Preliminary Diagnosis*:

Reason For Referral*:

Patient Information

Name*:

Date of Birth*:

Phone*:

Street*:

City*:

State*:

Zip*: