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.

Referral Date
MM slash DD slash YYYY
Patient Information
Patient Name*
Birthday*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email

If we cannot reach the patient by phone we will send them a follow up email.
Height (in)*
Weight (lbs)*
Reason For Referral*
Is this patient cleared for physical activity?*
- Yes
- No
Clicking "yes" indicates that the patient does not require medical supervision while performing physical activity.
Restrictions
Please indicate any restrictions that need to be observed while prescribing physical activity to this patient.
Referrer Information
Referrer*
Phone*
Email*
Office Address Address Line 2 City State / Province / Region ZIP / Postal Code
Additional Documents
Max. file size: 50 MB.
Use this section to upload in necessary documentation.

External WellnessWorks! Referral Form (Lawrence Memorial)

Patient Information

Referrer Information