PROVIDER REFERRAL FORM

PROVIDER REFERRAL FORM

www.insidehealthinstitute.org; info@insidehealthinstitute.org; phone: 425-256-2125, fax: 425-310-8166
Patient Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
Date
Patient's Phone Number

Area CodePhone Number
Patient's Email
example@example.com
Diagnosis codes (ICD-10)
I am referring my patient to Inside Health Institute for (select all that apply):

Counseling ServicesNaturopathic Medicine ServicesSIBO testingSIBO treatmentAcupunctureVerdant Health Equity Counseling ProgramOther
Please choose one:

Evaluate and Treat as IHI sees fitCo-manage this patient with meTransfer care of this patient to IHIOther
Referring Physician’s Contact Information:
Referring Physician Name

First NameLast Name
Referring Physician Phone Number

Area CodePhone Number
Referring Physician Fax

Area CodePhone Number
Referring Physician Email
example@example.com
Referring Physician Signature

Clear
Date

MonthDayYear
Date
Please note that patients who lack financial resources may apply for charitable assistance when funds are available.
Should be Empty: