Dietitian Referral Form

To book appointment: Phone: (902) 441-8852 or E-Mail referral to:

info@balancedproportions.com

Name of Referring Professional:

Referral Initiated by:
Family Physician ( ) Nurse (
Other:_________________

Pharmacist (

Dietitian (

Date of Referral
Patient Name
Patient DOB
Patient Location
Patient Phone #
Reason for
Referral
Recent Blood
Pressure
Relevant Lab Data**

Attached (
)

To follow (

Being Ordered (

Is this an urgent referral? (Patient to be seen within 2

weeks)
Has the referral been discussed with the patient?
Is the patient aware of diagnosis (if any)?
Comments

**Please attach or send a copy of relevant lab data. Relevant data include but are not
limited to: A1C, FBS, Lipid Profile, Hgb, ferritin, B12, microablbumin, creatinine etc. Results
should have been taken in the previous 3 months.

www.balancedproportions.com
E-mail: info@balancedproportions.com
Phone: 902.441.8852