Refer a Patient to Orthopaedic Services

Call 1-866-850-8863 Fax records to 801-581-4404

Now Taking Physician Referrals

Thank you for referring your patient to �鶹ѧ��Ʒ��. We value our relationship with referring physicians.

Please fill out the form below.

Fax applicable records to: 801-581-4404
Office hours: 8 am–5 pm

MedPic App for Orthopedic Spine Consultations

Physicians can receive orthopedic spine consultations from our dedicated providers at University Orthopaedic Center. We will give you recommendations for your patients within one hour from any location. The �鶹ѧ��Ʒ�� MedPic App gives your patients easy, HIPAA-compliant, collaborative care and follow-up.

QR code to scan and download the Medpic app for ortho spine consultations on the Apple store. — Scan the QR code to go to the App Store to download Medpic for iPhone.

QR code to scan and download the Medpic app on the Google Play store. — Scan the QR code to go to Google Play to download Medpic for Android.

Referring Provider Information

Provider Full Name (Last, First): ^*

Office Phone Number: ^*

Office Fax Number:

Office Address: ^*

Office/Clinic Name:

Referring to Information

Name of Requested Provider:

Specialty Department You Are Referring the Patient to: ^*

Preliminary Diagnosis: ^*

Reason for Referral: ^*

Urgency Rating:

Urgent 24-hour contact

Routine 48 hour

Patient Information

Patient Full Name (Last, First): ^*

Full Name of Parent or Guardian (If Minor):

Date of Birth: ^*

Gender:

Phone Number: ^*

Address: ^*

City: ^*

State: ^*

ZIP: ^*

If Interpreter Is Needed, Please Specify Language:

Insurance:

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