Request an Appointment—Lateral Team

With the Lateral Skull Base Tumor Team

To request an appointment for a consultation with the lateral skull base tumor team, please fill out the below form and click "submit".

No doctor referral is necessary to come visit us, but please check with your insurance first as some insurance companies require referrals.

Consultations

For your consultation, please send us your MRI scans and audiogram. We will schedule an appointment with you to discuss your diagnosis.

Please have ready:

a copy of the CD of your MRI images,
a copy of your audiogram (hearing test), and
copies of any balance testing (VNG) or auditory brainstem response (ABR) tests.

First Name: ^*

Last Name: ^*

Gender:

Male

Female

Other/Prefer Not to Answer

Date of Birth: ^*

Date of Birth:: Year ^*

Date of Birth:: Month ^*

Date of Birth:: Day ^*

Phone Number: ^*

Email: ^*

Address: ^*

City: ^*

State: ^*

Zip Code: ^*

Insurance Company: ^*

Group ID: ^*

Member Number: ^*

Active Date:

Please Note:

Not all insurance companies are considered "in network”, please call your insurance company by calling the number on the back of your card to confirm coverage using UUHC Tax id #876000525 and NPI #1588656870.

Reason for Visit/Past Diagnosis: ^*

Diagnosing Provider's Full Name: ^*

Diagnosis Date:

Location:

Phone Number:

Do You Have Past Imaging?
Yes

No

Imaging Date:

Imaging Facility:

If Possible, Would You Be Interested in Virtual Visits?
Yes

No

Please fax or have medical records faxed to 801-585-6087.

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