RLMI Jumpstart Referral Form
REQUEST FOR LIFESTYLE MEDICINE EDUCATION

The patient's email address is required, as it is the method we will use to contact them.  

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Referring Provider's Full Name: *
Referring Provider's Email Address: *
Referring Provider's Phone Number: *
Referring Provider's Fax Number: *
Referring Provider's Credentials (check all that apply):
PCP Name - If different from the referring provider:
Patient Name: *
Patient DOB: *
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DD
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Patient Phone Number:
Patient Email Address: *
If patient is under 18 years old, Parent name and contact information (phone or email):
Risk Factors (check all that apply):
Additional Comments & Special Patient Considerations:
Provider - Please order the following Pre / Post labs for your patient to fully benefit from Jumpstart:
  • Pre- and Post- Lipid Panel
  • Pre- and Post- Fasting Blood Glucose
  • Pre- HbA1c (if concerned about diabetes and not tested in the past 12 months)
  • hs-CRP (optional - to assess inflammation)
  • Any patient-specific lab work you feel is appropriate
Note:
Rochester Lifestyle Medicine Institute will follow up with your patient via email.

Teaching skills, not selling products...
Rochester Lifestyle Medicine Institute is a 501(c)(3) non-profit organization.
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