MNT Referral Form

Make Referring to Your Nutrition Practice Easy!

Streamline the referral process and make it effortless for medical providers to send patients your way. Create a custom referral form featuring your logo and contact information, and give it to providers’ offices to simplify patient referrals.

Key Features:

Customizable Referral Form: This is a Canva template, so you can add your own branding and tailor it for your services for a professional touch. It will be available for instant access directly on Canva. There are no pro/paid features used in this template. As this is a digital product, no refunds will be made.

Convenient for Providers: Ensure no barriers to referring by offering both printed and electronic versions of the form. Email or fax the referral form to a provider for them to keep on file. Make it super easy for the provider by filling in their name, NPI and phone number. Then, all they have to do is fill in the patient’s information and check off a diagnosis code for you to use for medical nutrition therapy.

Include in Outreach Packets: Pair the referral form with promotional materials, like brochures or flyers, to educate providers about your services and benefits for their patients. I customize the form with the provider’s information and deliver several copies to their office, accompanied by informative flyers (coffee never hurts, either;). This creates a welcoming opportunity to introduce yourself and establish a connection.

I like to personalize the form with the providers’ information, then bring several copies to their office along with some flyers (coffee never hurts, either;), paving the way for you to introduce yourself to them.

Electronic Distribution: Send the form digitally for easy access and use in providers’ offices. Make your services the go-to option for nutrition counseling by building relationships with providers and ensuring they have the tools they need to refer with confidence.

The MNT form features a selection of common ICD-10 diagnoses with checkboxes for the provider’s convenience. Additionally, it includes space for providers to input custom diagnoses as needed.

LICENSE: This file may not be shared, sold, or distributed as a standalone product. You are permitted to use it with your clients, but it cannot be sold separately to clients or colleagues.

PDF and Canva link included—easily customize with your logo, QR code, and contact information!