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DOCTORS REFERRAL FORM

Please fill out the following form.

Referral Date*

First name*

Last name*

Address*

Date of birth*

Month

Day

Year

Phone*

Email*

Gender*

Male

Female

Other

Preferred Contact*

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Text

E-Mail

MEDICAL NUTRITION THERAPY*

Initial MNT Assessment & Treatment

Follow-Up MNT Visit

Other

Other, please specify recent changes in weight, dx, medical condition, or treatment plan:

MEDICAL DIAGNOSIS*

771.3 Dietary counseling & surveillance

I10.0 Essential (primary) hypertension

R73.03 Pre-diabetes

E66.0 Obese due to excess calories

E78.0 Pure hypercholesterolemia

E10.0 Type 1 diabetes

E66.3 Overweight

E78.1 Pure hyperglyceridemia

E11.0 Type 2 diabetes mellitus

R62.51 Failure to thrive, child

E78.2 Mixed hyperlipidemia

N18.1 - N18.5 Chronic kidney diseases

R63.6 Underweight

E88.81 Metabolic syndrome

E28.2 Polycystic ovarian syndrome

Z68.30 - Z68.45: Medicare Intensive Behavioral Therapy (IBT) for obesity benefit

F50.00 - F50.9: Mental, Behavioral, & Neurodevelopmental Disorders

K21.0 - K86.0: Diseases of the Digestive System

Physicians Signature*

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Date*

H&P and Demographic Sheet*

Insurance Verification*

Ph: 918-585-3045 | Fax: 918-585-3047

115 West 3rd St, Ste 800 Tulsa, OK 74103

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