Refer a Patient | Vitality Weight Loss

Insurance Accepted Medicare, Medicaid, Humana, Cigna, UnitedHealthcare & CareSource. We're diligently working to be on every insurance possible.

Physician-Led Care Board-certified obesity medicine, not just a prescription

Fast Patient Outreach Our care team contacts your patient directly

Please do not upload medical records through this form. For chart notes, labs, medication lists, or insurance documents, fax securely to 702-988-8818.

Physician Referral Form

Basic patient information only. Our team handles the rest.

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Phone Number *

Email *

Insurance Plan *

Primary Reason for Referral *

Referring Provider

Practice / Clinic Name *

Referring Provider Name *

Provider NPI

Referring Office Phone *

Referring Office Email *

How did you hear about us?

How did you hear about Vitality?

Vitality rep (if a rep set this up)

Optional Clinical Details

Comorbidities

Current Weight or BMI

Preferred Language

Notes

Do not include full medical records here. Fax documents securely to 702-988-8818.

By submitting, you confirm you are authorized to share this patient information for referral.

Thank you. Referral received.

Our care team will contact the patient directly and follow up with your office if additional information is needed.

Sending records? Fax securely to 702-988-8818.

Refer a Patient to Vitality Weight Loss

Physician Referral Form

Thank you. Referral received.