Physician Referral Form

Clinicians & clinical staff:

Please provide the following information.

Patient's name

Patient's phone number

Patient's date of birth

Insurance

Member ID number

Diagnosis code

CPT code(s)

Ordering physician's NPI

Rendering physician's NPI

Physician phone number

Patients:

If you would like to be become a patient of Diabetes & Metabolic Wellness Center, please visit our appointment request page. This Physician Referral page is intended for clinicians to refer their patients to us.

830-730-4375

Monday through Friday
8 a.m. - 5 p.m.

info@dmwellnesscenter.com