Would you like confirmation from our team that your referral was received and that we've contacted your patient? Please ensure an email address is provided above if you'd like this follow-up. *

Yes

No

Referring Provider

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Referring Provider's Phone Number

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Referring Provider's Practice

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Patient's Name

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Patient's Email

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Patient's Phone Number

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Reason for Referral

Acid Reflux

GERD

LPR

Barretts Esophagus

Hiatal Hernia

IBS

SIBO

Gastroparesis

Bowel Irregularity

Functional Dyspepsia

IBD/UC

Gallbladder Dysfunction

Thyroid Conditions

Gut Health Optimization

By checking this box, I confirm that I have informed the patient about this referral to FLORA Nutrition. They are aware that someone from our team will reach out to provide more details about nutrition & lifestyle counseling. *

Yes I have notified this patient.