Refer a Patient: Infectious Diseases

Now Taking Physician Referrals

To refer your patient, please fill out the form below and click on the button labeled "Submit".

Referring Provider Name: ^*

Referring Office Contact: ^*

Referring Provider Phone:

Referring Provider Fax:

Referring Provider Email Address:

Referring Provider Npi Number: ^*

Physician

Patient Name:

Patient Phone:

�㽶��Ƶ Of Utah Health Medical Record Number (If Known):

Date of Birth:

Address:

City:

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ZIP Code:

Symptoms To Be Addressed: