pre-visit form

Pre-Visit Form

Before your first visit, please fill out the form and submit, or click here to download a printable form for you to bring in with you to your visit.

  • Medical History

  • I understand I will be charged for the full rate of each missed nutrition session if I do not call ahead with at least 24-hour notice, and these sessions will not be able to be made up in the future. I agree to pay for the full amount for the session at the time of service or, if a package deal, the full amount at the time of the first session (cash or personal check only; no credit cards). I agree to pay any amount that is not covered by my insurance. Prepaid appointments must be used within 3 months of purchase and weekly packages must be used within the allotted weeks. Unused sessions will be lost. I have read the above statements and understand the rescheduling protocol for my nutritional counseling sessions.