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Location: Lifetime Work, Beaverton 500 SW 116th Ave, Office 145, Beaverton, OR 97225
Phone: (971) 432-6232
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Patient Portal
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Patient Education
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Speaking
About
About Us
Testimonials
Location & Contact
Team Members
Doctor Awards
Offerings
For Patients
Patient Portal
Links to Labs
Patient Education
Patient Referrals.
Shop
Speaking
Book a Discovery Call
Patient Information
Patient Referral Form
Patient Information
Patient Referral Form
Patient Name:
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Reason for Consult
(Required)
Check all that apply
Cardiometabolic Consult
Weight Loss
Personal Training
Health Coaching
Body Composition Analysis
Group Cooking/Exercise Classes
Diagnoses
(Required)
Check all that apply
Overweight: BMI between 25 and 29.9
Obesity: BMI between 30-34.9
Obesity: BMI between 35 and 39.9
Obesity: BMI > 40
Obesity Hypoventilation Syndrome
Depression
Cancer
Hypertension
Hyperlipidemia
Coronary Artery Disease
Obstructive Sleep Apnea
Nonalcoholic Fatty Liver Disease
Type II Diabetes
PTSD
Physician Information
Referring Physician
Primary Care Physician
Referring Physician Fax
Primary Care Physician Fax
Referring Physician Phone
Primary Care Physician Phone
Referring Physician Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Primary Care Physician Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
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