External WellnessWorks! Referral Form (Lawrence Memorial)

Wellness Works! is a free 12 week program for individuals living with chronic conditions such as diabetes, obesity, hypertension, cancer, and COPD. This is a hidden referral application for external doctors, therapists, APRN’s, and other health professionals. Please fill out the referral below and the WellnessWorks! staff will reach out to the referred within 5 business days.

  • MM slash DD slash YYYY
  • Patient Information

  • If we cannot reach the patient by phone we will send them a follow up email.
    Clicking "yes" indicates that the patient does not require medical supervision while performing physical activity.
  • Please indicate any restrictions that need to be observed while prescribing physical activity to this patient.
  • Referrer Information

  • Max. file size: 50 MB.
    Use this section to upload in necessary documentation.