There are three options for submitting a referral.
- Take in the Physician Referral Form to your primary care physician at your appointment. Your physician will complete the form and submit it our our office.
- Your physician can use the link at the bottom of this website for Refer a Patient. our physician will complete the form and submit it our our office.
- Ask your physician to contact Memorial Weight Loss and Wellness Center directly.
Download Referral Form
For Intake Forms
The intake form should be completed prior to treatment. Download either a PDF or Word document, complete the form and fax to our office at 217-527-3209.
Download Word Document