PROVIDER REFERRAL

Connect your patient with Rising Rhythms

Refer a patient for additional nutrition, strength, behavior-change, and long-term maintenance support while they continue medical and medication management with their prescribing clinician.

Please confirm that your patient has agreed to have their contact information shared with Rising Rhythms and has given permission to be contacted about our services.

Patient Referral Form

Complete this brief form to introduce your patient to Rising Rhythms. Please do not include medical records or clinical information. Submission of this form does not enroll the patient or establish a care relationship.

01 — Referring Provider

02 — Patient Contact Information

Only provide the contact information the patient has authorized you to share. Do not include diagnoses, medications, symptoms, laboratory results, medical records, or other clinical information.

03 — Permission and Acknowledgment

I confirm that this patient is at least 18 years old, has agreed to have their contact information shared with Rising Rhythms, and has given permission for Rising Rhythms to contact them about its services.

I understand that Rising Rhythms provides education, coaching, nutrition and lifestyle guidance, and strength support. Rising Rhythms does not prescribe medication, adjust medication doses, diagnose medical conditions, provide emergency care, or replace the patient’s licensed medical provider.

Please do not submit confidential medical information through this form. Rising Rhythms will contact the patient directly with information about its services and next steps.

What happens next?

We contact the patient

Rising Rhythms sends the patient information about the available GLP-1 support program.

The patient decides whether to enroll

The patient can review the program, ask questions, and choose whether Rising Rhythms is a good fit.

Support begins after enrollment

If the patient enrolls and completes the required forms, Rising Rhythms provides support while their prescribing clinician continues to manage their medical care and medication.

Rising Rhythms provides education, coaching, and lifestyle support. Services do not include medical diagnosis, prescribing, medication adjustment, or emergency care and are not a substitute for care from a licensed medical provider. Submission of a referral does not guarantee enrollment, establish a clinician-patient relationship, or indicate acceptance of responsibility for the patient’s medical care.