Refer a Patient

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Thank you for trusting Retina Associates of Utah

Over 1,000 doctors from around the Intermountain West refer their patients to Retina Associates of Utah. We love what we do, and look forward to providing you and your patients with exceptional care and support. Please use the referral form below to get started.

For any eye related emergencies, please call us IMMEDIATELY at 801-312-2020. A physician is on call 24/7, including weekends and holidays.

asterisk (*) denotes mandatory fields

First Name of Patient *

Last Name of Patient *

Patient Email *

Patient Phone *

Which location would you prefer?

No PreferenceSalt LakeProvoLoganLaytonLehi

Patient DOB

Name of Rendering Physician at RAU *

Brief Description of Referral *

Name of Referring Doctor / Practice *

Doctor Phone *

Doctor Fax

Doctor Email *

Submit FormPlease leave this field blank.