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Dietitian Referral Form
Lauren Hofstee, RD · Registered Dietitian, College of Dietitians of Ontario
Virtual nutrition counselling across Ontario · laurenhofstee.me
Referring clinician
Clinician name
Designation (MD, NP, RN, etc.)
Clinic / practice
Phone / fax
Email
Date of referral
Patient
Patient name
Date of birth
Phone
Email
Reason for referral
Relevant history, medications, restrictions
I confirm the patient consents to this referral and to the sharing of relevant clinical information with the dietitian for the purpose of nutrition care.
Clinician signature
Date
Send securely online
or print and return by secure email or fax
Patients are typically seen within one to two weeks. A brief summary note is provided to the referring clinician with patient consent.