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FOR PROVIDERS

Fruits and veggies on your table, makes your health much more stable!

Berries

Referral for Medical Nutrition Therapy

Patient Name*
First Last
Patient Phone*
Patient Date of Birth
Date Format: MM slash DD slash YYYY
Nutrition Rx:
or use checkboxes below
Nutrition Therapy to be determined by RD for:
- Anemia/Vitamin/Mineral Deficiency
- Anti-Inflammatory
- Cancer
- CHF
- Chol/Dyslipidemia
- Diabetes/Borderline/Pre DM
- Food Allery/Sensitivity
- GERD/Other GI
- HTN
- Osteoporosis
- Pre/Post Surgery
- Sleep Apnea
- Weight Loss, Unplanned
- Weight Management, Desired Loss
- Other (entre ICD-9 Codes below)
ICD-10 Codes
Insurance Company*
Insurance ID Number*
Physician electronic signature and date*
Physician Name*
First Last
Physician Phone*
Physician Fax*
Referring Diagnosis/Other
Staff Email

EMAIL: INFO@NUTRITIONAUTHORITY.COM | PHONE: 1-855-EAT-4LIFE (328-4543)

PUYALLUP OFFICE

1002 39th Ave SW, Suite 200
Puyallup, WA 98373

IS PUYALLUP TOO FAR TO DRIVE?

ATI Physical Therapy has RDNs available closer to where you may live or work:

Bellevue 106th
Bellevue 112th
Bonney Lake
Bothell
Covington
Everett
Fairwood
Federal Way
Kent
Kirkland
Lakewood
Marysville
Mountlake Terrace
Newcastle
Olympia
Puyallup South Hill
Renton
Seattle – Downtown
Spanaway
Tacoma
Tumwater
Yelm

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