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Referring Providers/Groups

After completing the form below, patients will receive an automated email with instruction on booking their appoitnment. We will also reach out to the pt by phone/sms within 24 hrs of form submission (within 4 hours if urgent).

Referring Office
Patient Date of Birth
Month
Day
Year
Urgency
Urgent (Appointment needed same day)
Non-Urgent (will reach out and book pt within 24 hrs)

Fax any documents to our HIPAA complaint fax line: (385) 298-4566 For direct access to office, call (801) 406-1245

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