Palliative Care Referral

To refer a patient to the Utah Valley Palliative Care Clinic, please complete the form below. After submitting the form, please send a fax to (801) 357-7786 with a recent patient summary that includes:

Recent clinician chart/case notes
Admission H&P/Discharge summary from recent hospitalization
Current medication list
Pertinent labs, imaging, procedures
Current Advanced Directive/POLST, if available

Patient Name

Date Of Birth

Please use the date format DD/MM/YYYY (e.g. 11/28/1988)

Patient Phone Number

Patient Address

Patient City, State, Zip

Insurance

ID#

Referral Information

Reason for referral

Have you personally discussed this referral with the patient or significant other?

Yes
No

Primary Diagnosis

ICD code

Is the patient aware of their diagnosis & prognosis?

Yes
No

Date diagnosed

Please use the date format DD/MM/YYYY (e.g. 11/28/1988)

Co-existing disease or complications

Psychosocial concerns

Primary Care Physician is aware of the referral?

Yes
No

Primary Care Physician Name

Specialist(s) is aware of the referral?

Yes
No

Specialist(s) Name

Referral Contact Information

Provider

Phone

Best time to contact you

Other

Please enter the code shown above

Utah Valley Palliative Care Clinic

Patient Referral

Utah Valley Palliative Care Clinic Topics

Palliative Care Referral

Use Intermountain Connect Care®

Get in Line at InstaCare®

Emergency Care

Patient Referral

Utah Valley Palliative Care Clinic Topics

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Palliative Care Referral

Use Intermountain Connect Care®

Get in Line at InstaCare®

Emergency Care