Please only complete our New Patient Questionnaire once you have been accepted as a patient.

For details about our patient screening policies, please call our office at 801-685-7246.

We are looking for the following information:

• Demographic details: name, date of birth, phone number, and insurance details

• A complete medication list including the names of the medicines, the dose of each medication, and frequency that it is administered

• Imaging results: reports of recent MRI, CT or X-ray studies

  We do not need the images, the report findings is sufficient

• The last four visit notes from your current doctor

Please view our HIPAA Agreement and Privacy Policy.

Please send your information to our fax line at 801-747-5487.

New Patient Questionnaire