Refer a Patient

Dear Healthcare Provider,

Whether you’re:

• an orthopedic surgeon with a patient scheduled for joint replacement, who needs to lose weight prior to surgery
• a primary-care physician who has a gastric band patient who is having problems
• an nurse-practitioner with a patient who has diabetes and needs to lose weight

we are happy to assist you in any way!

Just fill out the form below and one of our patient-service representatives will call you back as soon as possible.  If you would prefer you can contact me directly at dr.c@thebanddoctor.com.

Sincerely,

Dr. Trace Curry

Refer a patient to Dr. Curry

Referring provider's name:

Referring provider's specialty:

I am referring this patient for:

Medical weight loss (meal replacements, phentermine, Qsymia, Belviq)

Surgical weight loss (sleeve, Lap Band, RNY)

Pre-surgical weight loss (e.g. pre-op joint replacement weight loss)

Complications or issues from prior bariatric surgery

Upper endoscopy

Patient Name:

Patient DOB:(required)

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Patient Cell #:

Patient Home #:

Clinical information:

Please enter any relevant clinical information here. If you would like a callback on this patient, please leave a name and contact number.

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