Provider Referral Form – The Green Leaf Clinic

Thank you for partnering with The Green Leaf Clinic.

Please complete this secure referral form to refer a client for functional or integrative health services, including chronic disease management, gut and hormone balance, and post-hospital follow-up care.

Our team will contact your client within 24–48 hours to schedule a consultation and will send you a brief update upon intake (with client consent).

Referring Provider / Organization

Referrer Email

Referrer Phone

Client Full Name

Client Phone Number

Client Email

Reason for Referral

Services Requested

Chronic Disease Management

Gut Health & Hormone Balance

Post-Hospital Follow-Up

Medication Review

Other (Please Specify)

Preferred Contact Method

Phone Email Either

I confirm that the client has provided consent for The Green Leaf Clinic to contact them for care coordination.

Attach referral letter or supporting notes (optional).

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