Online Referral Form: Heart Transplant

Now Taking Physician Referrals

Transplant Services is here to assist community physicians and specialists with consultation and referral services.To refer your patient, please fill out the information below and click on "Submit". You will receive a response within one business day.

Please be aware, we can only respond to your request during normal business hours, 8 am–5 pm, Mon–Fri.

Appointment/Evaluation

To make an appointment for a heart transplant evaluation at U of U Health, call 801-585-5122 or 800-824-2073. Before scheduling your appointment, we will check your insurance coverage to make sure the cost of the evaluation is covered.

Our team also will request medical records from your cardiologist to help plan your visit.

Contact Us

Phone: 801-585-5122
Toll-free: 1-800-824-2073 Ext. 53693
Fax: 801-213-3956
Email: Heart Transplant Team

Heart Transplant Referral Form

Patient Information

Name ^*

Date of Birth ^*

Gender

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Female

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Other

If you selected 'Other' for patient gender please specify how the patient identifies

Address ^*

City ^*

State ^*

Phone Number ^*

Insurance Information (if applicable)

Patient Diagnosis

Brief medical history ^*

Treatments ^*

Medications ^*

Referring Physician Information

Referring Provider Name, Title ^*

Referring Provider contact number(s) ^*

Referring Provider Email ^*

Referring Provider NPI Number ^*

Referring Office Address

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Call 801-585-5122 or

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