Refer a Patient

Now Taking Physician Referrals

Thank you for referring your patient to the John A. Moran Eye Center at the ��ο��Ƶ of Utah. We provide comprehensive, nationally ranked care in all ophthalmic subspecialties and value our relationships with referring physicians. Learn more about each of our specialists by browsing our Find an Eye Doctor tool.

Please call 801-213-2001 or fill out the form below to refer a patient.

Fax applicable records to: 801-213-6972
Office hours: 8 am–5 pm

Referring Provider Information

Referring Provider Full Name (Last, First) ^*

Referring Provider Email Address ^*

Referring Office Phone Number ^*

Referring Office Fax Number

Referring Office Address ^*

Referring Office/Clinic Name

Referring Provider NPI Number ^*

Referring to Information

Would you like to request a specific 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

First ^*

Middle/Initial ^*

Last ^*

Date of Birth ^*

Full Name of Parent or Guardian (If Minor) (Last, First)

Gender

Phone Number ^*

Street Address ^*

City/Town ^*

State ^*

ZIP/Postal Code ^*

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Insurance

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Refer a Patient

Now Taking Physician Referrals

Referring Provider Information

Referring to Information

Patient Information

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