Refer a Patient for the Heart Failure Program

Now Taking Physician Referrals

U of U ��г��Ƶ's Heart & Vascular ��г��Ƶ 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.

Referring Provider Information

Referring Provider Full name (Last, First) ^*

Referring Provider Phone Number ^*

Referring Office Fax Number

Referring Provider Email Address ^*

Referring Provider NPI Number ^*

Referring to Information

Type of Consult

Preliminary Diagnosis ^*

Reason for Referral ^*

Would You Like to Request a Specific Provider?

Yes

Please provide the name of the specific provider

Urgency Rating

Urgent 24-hour contact

Routine 48-hour

Patient Information

Full Name

First ^*

Middle/Initial ^*

Last ^*

Date of Birth ^*

Gender

Male

Female

Prefer Not to Answer

Other

Please Specify How the Patient Identifies

Phone Number ^*

Address

City/Town

State

ZIP/Postal Code

Submit Or Call 801-585-5122

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Refer a Patient for the Heart Failure Program

Now Taking Physician Referrals

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