Patient Referral Form
Estimated completion time ~ 5 mins
*We are looking forward to taking care of your patients
Patient's First Name?
Patient's Last name?
Date of Birth
What is your patient's height
what is your patient's weight
Does your patient have a PPO?
If PPO, please provide provider and member ID
Prefer not to say
Why are your referring your patient to Enara Health?
Type 2, controlled
Type 2, uncontrolled
Pre-existing DM with Pregnancy
BMI 30.0 - 35.9
BMI 36.0 - 39.9
BMI 40.0 - 70.0
You are referring for
MNT (2-3 hours)
DSMT ( 2-10 hours)
Intensive Behavioral and Medical Evaluation, Treatment, and Therapy for Obesity
Type II Diabetes Lifesyle Program (MNT, DSMT, and IBT for Obesity)
All medication changes are supervised by internal medicine physician. Our goal is to manage Obesity and Diabetes in conjunction with PCPs. Permission only apply to all diabetes and obesity related co-morbidities including including depression, HTN, and Cholesterol. If referring a patient for obesity management, second box must be checked to give Enara physicians the ability to optimize medications for weight loss. We update all PCPs of any medication changes immediately.
Enara Health providers are only allowed to make modifications to already prescribed medications. Any new prescriptions or medication replacements must be sent back to the PCP.
Enara Health providers are allowed to make medications modifications and/or prescribe/replace new medications if appropriate and update the PCP via a progress note.
Fax or secure email:
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