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

YYYY

What is your patient's height

what is your patient's weight

Does your patient have a PPO?

Yes

Medicare

Other:

Clear selection

If PPO, please provide provider and member ID

Gender?

Female

Male

Prefer not to say

Clear selection

Phone Number *

Why are your referring your patient to Enara Health? *

Type 2, controlled

Type 2, uncontrolled

Gestational Diabetes

Pre-existing DM with Pregnancy

Pre-diabetes

BMI 30.0 - 35.9

BMI 36.0 - 39.9

BMI 40.0 - 70.0

Required

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)

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.

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.

Referring Provider's:

Group/Physician Name *

Office Numbers:

Fax or secure email:

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