Fax all requests to 801-618-0920

We will contact the patient for you to schedule an appointment

Fax Your Own Form

Fax: 801-618-0920
Please make sure to include:
1. The reason for the study
2. Patient demographic info
3. Patient insurance info
4. Return fax number
5. Physician signature

Use Our Form

Click below to download our form
(or use your own)

Click to Download:

Call for Instructions

If you have specific questions not answered on this website, please call 801-871-5228