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
MM
/
DD
/
YYYY
What is your patient's height
what is your patient's weight
Does your patient have a PPO?
Clear selection
If PPO, please provide provider and member ID
Gender?
Clear selection
Phone Number *
Email
Why are your referring your patient to Enara Health? *
Required
You are referring for
Clear selection
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.
Referring Provider's:
Group/Physician Name *
Office Numbers:
Fax or secure email:
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