Patient Referral Forms

Click here to download and Fax the form

PKU GoLike Order Form

*Required fields

Referral Date

Patient Name

Patient DOB

Clinic Dietitian/Contact

Contact Phone

Contact Email

Patient Detail

Please either upload a file or complete the required fields below

Attach Patient Demographics

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Patient Name

Patient DOB

Parent or Legal Guardian, where applicable

Address

City

State

Zip Code

Phone

Allergies

Height

Weight

Emergency Contact

Relationship

Phone

Insurance Detail

Please either upload a file or complete some of the fields below

Insurance Information attached (including front and back of insurance cards)

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Primary Plan Name	Subscriber Name	DOB
ID #	Group #	Phone

Secondary Plan Name	Subscriber Name	DOB
ID #	Group #	Phone

Prescriber Detail

Prescriber Name
NPI		License #
Address
Phone	Fax	Email	Preferred Communication Method Phone Email Fax

Click box to attach below:
You are only able to attach a maximum of 20 documents per submission.

Recent Clinical Note

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LMN Signed By Prescriber

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Order

ICD-10 / Diagnosis Description (select): *

E70.0: Classical phenylketonuria

E70.1: Other hyperphenylalaninemias

Other

Product Selection - Select ALL that apply *	Units per Day	Boxes per Month
PKU GOLIKE Plus Granules (Ages 4-16; 15g P.E.); 30 x 0.8oz Packets
PKU GOLIKE Plus Granules (Ages ≥ 16; 20g P.E.); 30 x 1.1oz Packets
PKU GOLIKE Medical Food Bar Berry (10g P.E.); 10 x 2oz Bars
PKU GOLIKE Medical Food Bar Tropical (10g P.E.); 10 x 2oz Bars

If you are unable to upload supporting documentation above, you can still sign and submit the referral form by selecting "Submit" below and faxing supporting documentation to Pentec at 866-869-9442.

Patient Referral Comments

Once your form has been submitted, please download a copy to sign and fax to 866-869-9442

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