Refer a Patient for a Dietitian Consultation

Disclaimer: Blood Cancer United offers the Nutrition Education Services Center for information and education purposes only. It is not intended to provide medical diagnosis, treatment or therapy. LLS is not able to assist patients with urgent medical needs that require immediate attention. By completing and submitting this form, you represent you are authorized to share the information below, including the patient's medical information, with LLS. For more information about our nutrition consultations, click here.

Referral Source Information

Referral Made By*

I am a...

Other healthcare professional

Hospital or Treatment Center

Zip Code of Hospital or Treatment Center

Email*

Phone Number*

How did you hear about the Blood Cancer United Nutrition Education Services Center?

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Disclosure Agreement

By checking this box, I agree that I have explained Blood Cancer United Nutrition Education Services Center services to the patient, and the patient agrees to the disclosure of this information to Blood Cancer United for the purpose of follow-up

Complete the disclosure agreement to continue with the form and provide patient information.

Patient Information

Patient's Name*

First Last

Date of Birth

Gender

Race (Select all that apply.)

American Indian or Native Alaskan
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Some Other Race
Prefer Not to Answer

Is the patient of Hispanic, Latino or Spanish Origin?

Yes
No
Unknown

Has the patient ever served on active duty in the U.S. Armed Forces, Military Reserve, or National Guard?

Yes
No
Unknown

Should we contact the patient or the caregiver?*

Patient
Caregiver

Patient/caregiver's preferred language

English
Spanish

Phone interpreter services are available.

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Patient/Caregiver's preferred language (if not English):

Phone interpreter services are available.

Patient Phone Number

Patient's Email

Caregiver's Name

Caregiver's Relation to Patient

Caregiver's Phone Number

Caregiver's Email

Street Address

City

State

Zip Code

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ZIP Code

Diagnosis*

Subtype

Other Diagnosis

Date of Diagnosis

(if unknown, see below)

Approximate date of diagnosis if actual date is unknown

Is the patient inpatient?*

Yes
No

What are the patient's nutrition needs? (Select all that apply.)*

Other- Please Describe

What is the reason for this referral? Please include any additional details in the space below.

The more information the registered dietitian has, the more effective the consultation will be.

Once the referral is received by a Nutrition Education Services Center representative, we will contact your patient to schedule a consult with the dietitian.

Referral Source Information

Patient Information

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