EST. 2009

Moorhead, MN & Plymouth, MN

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Patient Referrals

Referral Form

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Patient Name: *

DOB: *

Month

Day

Year

Address 1 *

Address 2

City *

State *

ZIP code *

Address: *

Phone: *

Email:

Preferred method of contact: *

Phone

Text

Diagnoses or Symptoms: *

Does the patient have any of the following:

Pacemaker

Metal in body

Hearing Aids

Pregnant

Location of metal in body:

Please select referral purpose: *

New Patient Naturopathic (evaluation and treatment)

Pediatric Nurse Practitioner Patient (evaluation and treatment)

Well Child Exam

Detox Program

Naturopathic Physiotherapy (NPT)

Diathermy (sinus/lung/abdomen/musculoskeletal)

Low-Level LASER Therapy

Glucosamine Iontophoresis Treatments

Naturopathic Manual Therapy (evaluation and treatment)

Visceral Manipulation

Craniosacral Therapy

Naturopathic Somato-Emotional Therapy (NSET)

HeartMath Biofeedback

Number of Tx (optional):

Frequency & length of Tx (e.g. 2x/week x 3 weeks) (optional):

Particulars to be aware of (particular provider to be seen if desired):

Referring Provider Name: *

Clinic if applicable: *

Phone: *

Date: *

Month

Day

Year

Referral Location: *

Moorhead, MN

Plymouth, MN

Leave this field blank

Instructions

Please fill out the referral form as completely as possible before submission. This form is intended for professional providers to refer services to Prairie Naturopathic Doctors.

PND Healthcare Providers

Moorhead, MN
Dr. Todd Ferguson, ND
Dr. Molly Ferguson, ND
Dr. Sophia Fox, ND
Dr. Whitney Grier, ND
Megan Klinkhammer, APRN, CPNP

Plymouth, MN
Dr. Brianna Vick, ND

Follow our Moorhead Location

Follow our Plymouth Location

3 Pnd Logo Boxed Web

1506 30th Ave. S.
Moorhead, MN 56560
(218) 284-1188

3140 Harbor Lane Suite 102
Plymouth, MN 55447
(612) 236-0002

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Medicinary & Scheduling Hours

Moorhead, MN
Mon.: 8am-6pm
Tue.: 8am-5pm
Wed.: 11am-6pm
Thur.: 8am-5pm
Fri.: 8am-1pm

Plymouth, MN
Mon.: 1 pm-4pm
Tue.: 8am-12pm; 1pm-4pm
Wed.: 1pm-4pm
Thur.: 8am-12pm; 1pm-4pm
Fri.: 9 am-11am