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 fees, I am in network with Blue Cross, United Healthcare, Select Health, and Medicare and will submit your claim on your behalf. Please call your insurance prior to your appointment to check if dietary counseling is part of your specific plan; specifics on how to do this were sent to you in the New Patient Paperwork email. For other insurances, upon request, I can provide you a receipt to submit to your insurance provider for potential reimbursement.

    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 ensures that even if your diagnosis is not covered by Medicare, the claim can be submitted for payment to your secondary insurance.

    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 a provider with Blue Cross, Regence, United Healthcare and Medicare insurances. 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. 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 Number
  • 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
232 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!

© 2022 Nourish Your Life – Sandy Kipp Registered Dietitian All Rights Reserved
Powered by Valice