The Wellness Center Exercise is Medicine Referral Form

  • Physician and health care provider instructions for the Wellness Center EIM program:
    1. Assess patient's exercise habits and encourage patient to increase physical activity if appropriate.
    2. Refer appropriate patients to the Wellness Center for Health & Fitness EIM Program (minimum age 15 yrs).
    3. Complete form and fax to 504-503-6800 or Patient will be called to schedule appointment.
    4. You will receive confirmation of patients participation and progress in the program.
  • Patient's Information
    • MM slash DD slash YYYY
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  • Health Care Provider
  • The Wellness Center for Health & Fitness EIM Program Includes:
    1. Health Assessment.
    2. Exercise prescription tailored in patients choice of environment and exercise preferences.
    3. Nutritional Counseling
    4. Three month membership to the Wellness Center
  • This field is for validation purposes and should be left unchanged.