Get Patient Referral Form - Utah Gastroenterology

This guide provides a simple, step-by-step process for completing the Patient Referral Form for Utah Gastroenterology online. Follow these instructions to ensure accurate and efficient submission of your referral.

Follow the steps to complete your patient referral form online.

1. Press the ‘Get Form’ button to access the Patient Referral Form and open it in your document management tool.
2. Begin by entering the date at the top of the form. This helps to maintain an accurate record of your submission.
3. Fill in the patient's full name in the designated field.
4. Choose the patient's gender by circling either 'Female' or 'Male'.
5. Input the patient's date of birth in the space provided.
6. Provide contact information, including home, cell, and work phone numbers, using the specified fields.
7. Identify the referring physician's name, ensuring to include their phone number for any necessary communication.
8. Enter the primary care physician's name and the name of the insurance company in the respective fields.
9. Select the reason for the referral by checking the appropriate box. Options include GI Consult, Colonoscopy, EGD, or Other.
10. Indicate the urgency of the referral by circling either 'ASAP' or 'Routine'.
11. Choose a physician from the provided options based on the location of the office (Bountiful, Murray/TOSH, Old Mill, Riverton, St. Mark's, or Lone Peak). You can select ‘First Available’ if no specific preference exists.
12. Complete any additional required information and ensure all fields are correctly filled.
13. Once all sections are completed, you can save, download, or print the form. To submit it, fax the completed form to the appropriate office using the fax numbers listed.

Complete your Patient Referral Form online today to ensure timely processing of your referral.