Refer A Patient for Neurosurgery

Now Taking Physician Referrals

Consultation & Referral ��г��Ƶ

Our specialists are here to assist community physicians and specialists with consultation and referral services. To refer a patient, please complete our online physician referral form and fax all related clinic notes and diagnostic reports to us. Once the form is completed, you will receive a return email confirming your referral and providing you with a referral tracking number in case you would like to follow-up or provide additional information at a later time.

The information submitted will be reviewed promptly to ensure that the proper neurologist or neurosurgeon evaluates each case, and the patient will be contacted about an appointment.

Contact Us:

Phone: 801-585-6065
Fax: 801-585-6087

Referring Physician Information

Referring Provider Full Name:

Referring Office Contact:

Department (If Applicable):

Referring Phone Number

Referring Provider Fax

Referring Provider Email Address:

Referring Provider Npi Number

Type Of Physician

Referring To

Urgency Rating

Would You Like To Request A Specific Provider?

Yes

Patient Information

First Name

Last Name

Date Of Birth

Patient's Gender

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

Address:

City:

State:

ZIP:

Phone

Secondary Phone

��г��Ƶ Of Utah ��г��Ƶ Medical Record Number

Neurological Symptoms To Be Addressed

Has The Patient Had An MRI?

Yes

If Yes To The Above Please Provide The MRI Date

Has The Patient Had An CT?

If Yes Please Provide The Ct Date

Has The Patient Had An X-Rays

Yes

If Yes Please Provide The X-Ray Date

Insurance Information

Primary Insurance Policy Number

Policy Holder

Phone Number

Insurance Provider

Secondary Insurance

Policy Number

Policy Holder

Phone Number

Insurance Provider

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