Exercise is Medicine Referral Form - East Jefferson General Hospital

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 fitness@ejgh.org. Patient will be called to schedule appointment.
4. You will receive confirmation of patients participation and progress in the program.
Patient's Information
- Name*
- D.O.B.*
  MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- Phone*
- Email*
Patient completes 150 minutes/week of exercise and strength trains twice/week?*
- Yes
- No
- Reason for referral*
- Health concerns/restrictions*
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Health Care Provider
- Name*
- Practice*
- Fax*
Signature*
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
Name
This field is for validation purposes and should be left unchanged.

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