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You can inform your patient that Carol will be in contact with them within 3 business days using the contact information provided on the form.
If they'd like to read about Carol, please provide them with this handout. ********
refer your patient
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Indicates required field
Your patient's first and last name:
*
Patient DOB:
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Patient phone number:
*
Patient email address:
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Is your patient cleared to exercise?
*
Fully cleared to exercise
Needs provocative cardiac testing before exercising
Only low intensity exercise
No, patient should not exercise
Referring Healthcare Provider name:
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Referring Healthcare Provider phone number:
*
Please include anything you'd like to communicate with Carol below:
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Home
Weight Loss Coaching
Blog
weight loss course
About
Contact