HEALTH COACHING REFERRAL
Once your referral is received, we will contact your patient with a complimentary consultation to discuss their unique health challenges, obstacles, goals and to help them to determine whether or not they want to move forward with working together.
Today's Date*
Referring Doctor Information
Full Name*
Phone Number*
Email*
Practice Adress*
Patient Information
LYFE Balance, Inc., complies with the Health Insurance Portability and Accountability Act of 1996.
Account
Name*
Phone Number*
Referral Reason*
Referring Doctor's Comments
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