Patient Referral Form
Estimated completion time ~ 5 mins

*We are looking forward to taking care of your patients

Patient's First Name? *
Your answer
Patient's Last name? *
Your answer
Date of Birth
MM
/
DD
/
YYYY
What is your patient's height
Your answer
what is your patient's weight
Your answer
Does your patient have a PPO?
If PPO, please provide provider and member ID
Your answer
Gender?
Phone Number *
Your answer
Email
Your answer
Why are your referring your patient to Enara Health? *
Required
You are referring for
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 *
Your answer
Office Numbers:
Your answer
Fax or secure email:
Your answer
Submit
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