Ixcela

Patient Referral Form

Please complete the form below to refer a patient to Ixcela. Once you complete the form, an Ixcela Navigator will contact your patient within 1-2 business days to ask a few questions and schedule an appointment.

Provider First Name: *

Provider Last Name: *

Provider Credentials:

Provider Phone Number: *

Provider Email: *

Your Practice Zip Code: *

Patient First Name: *

Patient Last Name: *

Patient Phone Number: *

Reason(s) for referral (Check all that apply): *

Type 1 diabetes

Type 2 diabetes

Pre-diabetes

Dislipidemia

Hypothyroidism

Cardiac disease

Hypertension

Nonalcoholic Fatty Liver Disease

Irritable Bowel Disease (IBD)

Irritable Bowel Syndrome (IBS)

Acid reflux or GERD

Diverticulitis

SIBO

Celiac disease

Overweight or obesity

Underweight

Food allergies or intolerances

Osteoperosis or osteopenia

Malignant (primary) neoplasm, unspecified

Other

Other Reason: *

ICD-10 Code(s):

Other notes: