Refer a Patient to General Surgery

Now Taking Physician Referrals

Thank you for referring your patient to �㽶��Ƶ of Utah Health. We value our relationship with referring physicians. Please fill out the form below.

If you are trying to reach colorectal, here is the fax number: FAX 801-585-1520

Referring Provider Information

Referring Provider Name ^*

Referring Provider Email Address ^*

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Referring Provider Fax Number

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Preliminary Diagnosis ^*

Reason for Referral ^*

Patient Information

First Name ^*

Last Name ^*

Date of Birth ^*

Patient's Gender

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