Health Care Home Pain Management Center Refer a Patient to the Pain Management Center Call 801-581-2988 You must have JavaScript enabled to use this form. Now Taking Physician Referrals Learn more about patient safety precautions, virtual visit options, and referring physician resources. To refer a patient online, please fill out the information below and click on the button labeled "Submit". You will receive a response within one business day. Please be aware, we can only respond to your request during normal business hours, 8 am–4:30 pm, Mon–Fri. Please fax the patient's demographics, past medical history, and information about their last physical to 801-585-3274. You may call the clinic at 801-581-7246 for general questions. Patient Information Patient First Name: * Patient Last Name: * Date of birth: * mm/dd/yyyy Reason For Referral/Consultation: * Additional Notes: Referring Physician Information Referring Physician First Name: * Referring Physician Last Name: * Referring Provider Phone: * Referring Provider Email: * Referring Provider Fax: * Referring Provider NPI Number: * Leave this field blank
