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Clinician Referral Request

Lauren Hofstee, RD · Registered Dietitian, College of Dietitians of Ontario

Virtual nutrition counselling across Ontario · laurenhofstee.me

Referring clinician

Clinician name

Designation (MD, NP, RN, etc.)

Clinic / practice

Phone

Work email

Client

Client name

Phone

Age range

Area of support

Anything useful for first contact

Please keep this brief. Do not include detailed medical history, medications, diagnostic reports, or other sensitive records here. Lauren will arrange an appropriate way to exchange additional clinical information if it is needed.

This form starts a connection. It does not establish a care relationship or guarantee an appointment.

Lauren reviews the request and contacts the client or referring clinician to confirm fit and current availability. This service is scheduled outpatient virtual nutrition care. It does not replace urgent medical assessment, crisis support, medical monitoring, or a higher level eating disorder program.