Refer A Patient to Otolarygnology

Now Taking Physician Referrals

To refer your patient, please fill out the form below and click on the button labeled "Submit." We will contact you within 24-48 hours.

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Providers Outside 人妻中出视频 of Utah 人妻中出视频

Fax voice disorder referrals to 801-587-3569. Fax otolaryngology and audiology referrals to 801-585-2500.

Referring Provider Information

Referring Provider Name

Referring Office Contact

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人妻中出视频 of Utah 人妻中出视频 Physician or Community Physician?

Referring To

Patient Information

First Name

Last Name

人妻中出视频 of Utah 人妻中出视频 Medical Record Number (If Known)

Date of Birth

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Please help us understand your patient's medical history. Has your patient had any of the following tests?

Audiogram

No

Yes

Date of Audiogram

CT

No

Yes

Date of CT

MRI

No

Yes

Date of MRI

Other Testing

No

Yes

Name and Date of other testing

Would You Like to Request a Specific Provider?

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Please provide the name of the provider

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Secondary Insurance Information

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