Patient Referral Form
Estimated completion time ~ 5 mins

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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?
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If PPO, please provide provider and member ID
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Phone Number *
Why are your referring your patient to Enara Health? *
You are referring for
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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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