referral form for medical nutrition therapy (providers only)

LG Nutrition welcomes referrals from other health practitioners. We frequently receive referrals from physicians, physical therapists, functional medicine doctors, chiropractors, naturopaths, dentists, acupuncturists, and mental health providers. Please complete the form below to refer a patient.

Please note if patient has Medicare insurance and is being referred for diabetes or renal disease, please use our fax referral form.

I attest that patient has provided authorization for information in this referral to be submitted to LG Nutrition.

Patient authorization is on file with provider.

Patient Name

First Name

Last Name

Patient Contact Phone Number

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Name of Referring Provider

Provider NPI #

Name of individual submitting request (if other than provider)

Provider Contact Email Address

Provider Contact Phone Number

(###)

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Reason for referral (include ICD-10 codes)

Additional information about this referral.