Integrative Medicine Physician Referral Form

Integrative Medicine Program

at East Jefferson General Hospital

PHYSICIAN REFERRAL FORM

How can your patients participate in the Integrative Medicine Program at EJGH?

Complete this form and fax to: 503-6800 or email to: livingwell@ejgh.org.
It is highly recommended that your patient visit the EJGH Oncology Nurse Practitioner.
Once steps 1 and 2 are completed, EJGH will contact your patient to schedule services.
Once therapy is completed, a physician report will be faxed back to you.

Patient Information

Patient's Name*
Patient's Phone*

Patient's Date of Birth*
MM slash DD slash YYYY
Date Faxed**
MM slash DD slash YYYY

For Ordering Physician Use Only

Please check the appropriate box(es):

It is my understanding that the above named patient would like to participate in the Integrative Medicine Program at EJGH. An Integrative Medicine evaluation with an EJGH Nurse Practitioner is highly recommended before beginning any activity.

I would like for the above named patient to participate in the following:

Patient Participation

I know of no reason why the patient cannot participate.
I believe the patient can participate, but I urge caution because of the following: (Provide detail below.)
I believe the patient can participate, but should not engage in the following activities: (Provide detail below.)
I recommend that the patient not participate.

Please clarify your previous selection.

Comments

Physician's Name
Date
MM slash DD slash YYYY

Physician's Signature

Physician's Phone
Physician's Fax

Form may be submitted online, faxed to: (504) 503-6800 or emailed to: livingwell@ejgh.org

East Jefferson General Hospital

Integrative Medicine Program • 3726 Houma Blvd., Metairie LA 70006 • phone: 504-503-6000 • fax: 504-503-6800 • email: livingwell@ejgh.org

ejgh.org/livingwell

Phone

This field is for validation purposes and should be left unchanged.

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