Thank you for visiting NutritionRx! We invite you to make an appointment to come and see us. In order to give you the best NutritionRx possible, we ask that you read and fill out the following forms and bring them with you to your initial consultation. In addition to supplying you with important patient information, these forms will also give our dietitians a glimpse into your relationship with food, allowing us to provide you with a tailored session.
To send us the completed forms simply save the downloaded forms as Word files, fill them out on your computer, and attach them in an email to firstname.lastname@example.org at least 24 hours prior to your scheduled appointment.
o HIPAA Notice of Privacy Practices - PDF
o Release of Information Form - PDF
o New Patient Registration - PDF
o Health & Medical History - PDF
o Food Journal - PDF
o Credit Card Intake Form - PDF
o Billing & Cancellation Policy - PDF
o Insurance Reimbursement Policy - PDF
o Patient Welcome Packet Rules of Engagement - PDF