Refer A Patient to Women's Health Services

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.

Fax applicable records to: 801-585-5146

Office hours: 8 am–5 pm

Referring Physician Information

Referring Provider Full Name: ^*

Referring Provider Email Address: ^*

Referring Phone Number: ^*

Referring Provider Fax:

Referring Provider Npi Number: ^*

Referring Office Address: ^*

Referring Office/Clinic Name:

Referring to Information

Would You Like To Request A Specific Provider?:

Specialty Department You Are Referring The Patient To: ^*

Preliminary Diagnosis: ^*

Referring To: ^*

Urgency Rating:

Patient Information

First Name: ^*

Last Name: ^*

Date Of Birth: ^*

Full Name Of Parent Or Guardian (If Minor) (Last, First):

Patient's Gender: ^*

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

Phone: ^*

Address: ^*

City: ^*

State: ^*

ZIP: ^*

If Interpreter Is Needed, Please Specify Language:

Insurance: