Skip to content

Nourish Your Life – Sandy Kipp Registered Dietitian

  • About
    • About Sandy
    • Education and Credentials
  • Services
    • Nutrition Counseling
    • Food and Chemical Hypersensitivity
    • Chronic Disorder Therapy
  • Resources
    • Meal Plans
    • Favorite Kitchen Tools
    • Articles
  • Forms
    • New Patient Form
    • Symptom Survey
    • Food Journal
    • Patient Acknowledgement
    • Medicare Advanced Beneficiary Notice
  • Contact
    • Contact
    • Frequently Asked Questions
    • Privacy Policy

New Patient Form

Step 1 of 7

14%
  • Welcome to the road to better health. I am delighted to be on this journey with you! Here are a few details as we move toward your nutrition consultation:

    Please complete this form prior to your consultation, along with the other forms listed under Patient Forms.

    Regarding insurance, please refer to the New Patient Paperwork email that I sent to you after you made your appointment. If you are not using insurance I offer a $150 per hour discounted rate for prompt private pay which is payable by cash, check, credit card, Venmo or health savings plan, and due at the conclusion of our appointment.

    If you are a Medicare recipient you will need to fill out and sign the Advanced Beneficiary Notice (ABN). This is a requirement of Medicare.

    If you have any questions feel free to contact me.

    I look forward to working with you!

  • Patient Information

  • MM slash DD slash YYYY
  • Click "+" to add more
    NamePhone 
  • I am in network with Blue Cross, Select Health, United Healthcare and Medicare insurances under the name Sandra Kipp. If you have one of these, please call ahead for coverage of dietary counseling. If needed, please call your doctor's office and ask them to fax (888.972.6280) your "diagnosis code" to my office either as a referral or on letterhead (please see more detailed instruction in the email that I sent to you entitled "New Patient Paperwork"). If you are over 65 and have United Healthcare we must acquire preapproval prior to your appointment. If this is the case, please contact me now as we may need to reschedule your appointment.
    Provider NamePolicy NumberPrimary Member's NamePrimary Member's Date of Birth 
  • Health Goals

  • Medical History

  • 1 - Very Unhealthy2345 - Very Healthy
  • (women only)
  • (use "+" to add more)
    Medication/SupplementDoseFrequencyReason 
  • Family History

  • (click "+" to add more)
    Family memberCondition 
  • Readiness Assessment

  • 1 - Not Willing2345 - Very Willing
    Significantly modify your diet
    Engage in regular physical activity
    Modify your lifestyle (work demands, sleep, exercise)
    Keep a record of everything you eat
    Practice relaxation techniques
    Take supplements for nutrition therapy
    Have a lab test performed for a health assessment
  • Lifestyle Information

    Exercise

  • (click "+" to add more)
    ActivityType/Intensity (low-moderate-high)# Days Per WeekDuration (minutes) 
  • Sleep

  • 1 (Poor)2345 (Great)
  • Social

  • Stress

  • 1 - Low2345 - High
    Work
    Family
    Finances
    Health
    Other
  • Environment

  • Nutrition and Digestion Information

  • This field is for validation purposes and should be left unchanged.

Nourish Your Life – Sandy Kipp Registered Dietitian

Phone: 208-250-0836

Fax: 888-972-6280

Facility Address
1105 2nd Street South
Nampa, Idaho 83651

Services & Resources

  • Services
  • Meal Plans
  • Favorite Kitchen Tools
  • Articles

About

  • About Sandy
  • Education and Credentials
  • Frequently Asked Questions

Information

  • Contact
  • Patient Forms
  • Privacy Policy
Nourish your body, nourish your mind, nourish your soul!

© 2023 Nourish Your Life – Sandy Kipp Registered Dietitian All Rights Reserved
Powered by Valice