Refer A Patient for Neurology & 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: 801-585-7575
Fax: 801-585-2746

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:

�����г���Ƶ