Refer A Patient—Plastic Surgery

Now Taking Physician Referrals

Thank you for referring your patient to 91�鶹��ֱ��. We value our relationship with referring physicians. Please fill out the form below or submit your request through the U of U Health MedPic app.

Fax applicable records to 801-581-5794

Office Hours: Monday to Friday 8 a.m. – 5 p.m.

If this is an urgent request, please call 801-581-7719 during office hours or 801-581-2121 outside of office hours.

Referring Physician Information

Referring Provider Full Name: ^*

Referring Office Contact: ^*

Referring Phone Number: ^*

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Patient Information

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

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ZIP:

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University Of Utah Health Medical Record Number:

Insurance Information

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Secondary Insurance

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Insurance Provider: ^*

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