NUTRITION CONSULT

Date

Name

First NameLast Name

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Weight

Age (years)

How did you hear about Mindset Nutrition?

My main goals are focused around

List any preexisting conditions:

What is your reason for seeking nutritional guidance?

What do you typically eat in a day?

Do you have any food allergies or intolerances? If yes, list below.

Do you take any supplements or vitamins? If yes, list below.

What foods do you crave the most?

Do you have any concerns with your current eating habits? If yes, explain below.

What is your current eating style?

I like to track my foodI will track my food but not long termI like to eat mindfully and not trackI have no idea

CANCELLATION POLICY: I will provide 24 hours notice if I need to cancel my appointment for any reason, otherwise I will be charged $50 cancellation fee, NO EXCEPTIONS. I can cancel via email at: erin@mindsetnutritionstl.com or via text: (314)518-2685

I understand, and will comply

Erin Darling MA,MS, is not considered your primary care physician. Mindset Nutrition asks that you maintain a relationship with a primary care physician to address any pertinent medical needs. Erin Darling MA,MS, does not service medical emergencies. If you have a medical emergency, you must contact your primary care physician or dial 911.

Payment is due at time of service - no exceptions. Virtual appointments will be due prior to the zoom. If you fail to pay for your appointment, all future appointments will be on hold, till payment is made. Methods of payment we accept are: Visa, MasterCard or American Express, check or cash. If you are unable to keep your scheduled appointment, you must notify our office a minimum of 24 hours before your scheduled time or you will be financially responsible for the full price of your appointment. Cancellations can be made through email at erin@mindsetnutritionstl.com or via text: (314)518-2685

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