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 Name *
Patient Name
Patient Contact Phone Number *
Patient Contact Phone Number
Provider Contact Phone Number *
Provider Contact Phone Number