New Patient Form

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

Name*

First Last

Preferred Name

Date of Birth*

Age*

Gender*

Male
Female

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Phone*

Secondary Phone

Email*

Please mark all the ways that I may contact you:*

Phone
Email
Text

Is it OK to leave a phone message?*

Yes
No

What is the best way to contact you?*

Phone
Email
Text

Primary Physician and Other Providers

Click "+" to add more

Name	Phone

Referred by (doctor's office, friend, my website, Internet search, Google ad, HealthProfs, etc.)*

Insurance Provider (if applicable)*

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 Name	Policy Number	Primary Member's Name	Primary Member's Date of Birth

Height*

Current weight*

Usual weight range*

Desired weight (if applicable)

Have you had any recent weight gain or loss?*

Yes
No

Please describe

Medication/Supplement	Dose	Frequency	Reason

	1 - Not Willing	2	3	4	5 - 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

Activity	Type/Intensity (low-moderate-high)	# Days Per Week	Duration (minutes)

	1 - Low	2	3	4	5 - High
Work
Family
Finances
Health
Other

Step 1 of 7

Patient Information

Health Goals

Medical History

Family History

Readiness Assessment

Lifestyle Information

Exercise

Sleep

Social

Stress

Environment

Nutrition and Digestion Information

Family member	Condition