Nutrition Counseling at Drexel University Registration Form

Name*

First NameLast Name

Date of Birth*

Email Address*

example@example.com

Gender*

MaleFemaleOther

Preferred Phone Number*

Please enter a valid phone number.

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Driver's License/Personal Identification Card*

How did you hear about Drexel Nutrition Counseling Services?

Who referred you to us?*

Please select the option below that best reflects the reason for your visit so that we can ensure your session is tailored to you and your needs/goals.*

Additional information you would like to share:

Primary Insurance

The Drexel University Registered Dietitian Nutritionists (RDNs) are providers for many of the major insurance companies, however insurance coverage for nutrition services varies greatly depending on policy type and medical diagnosis. You will be responsible for any balance not covered by insurance, and your RDN will make you aware of this prior to your session.

Please select your health insurance company:*

If your insurance provider is not listed above, please provide it below:

Self-Pay

Insurance Member ID #*

Group ID #

Primary Insured*

SelfSpouseParentOther

Information of Primary Insured (if not self)*

First NameLast Name

Date of Birth of Primary Insured (if not self)*

Primary Insured Address (if not self)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Front of Insurance Card*

Back of Insurance Card*

Telehealth Consent Form

Defining Telehealth: Telehealth is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telehealth consultation with a provider details of your medical or health history and personal health information may be discussed through the use of interactive audio, video, and/or other telecommunications technology, and the provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means, and verify your identity with a driver's license or other legal document.

Disclaimer: The telehealth services you receive from providers are not intended to replace a primary care physician relationship or be your permanent medical home. You should seek emergency help or follow-up care when recommended by a Provider or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended. We may make arrangements for follow-up care either through the provider, a health systems partner, or other health care providers.

Failure of Technology Protocol: If the transmission fails during your telehealth consultation with a registered dietitian, then your provider will contact you to help you get reconnected. Attempt to reconnect will be made till the end of the scheduled session.

Benefits & Risks of Telehealth: Among the benefits of staying on track with your nutrition healthcare plan with your registered dietitian, telehealth services provide improved access to health care professionals and convenience. However, there are potentials risks associated with the use of telehealth. These risks include, but may not be limited to:

-In some instances the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the provider (i.e., poor resolution images, etc.);

-Delays in evaluation or treatment could occur due to failure of the electronic equipment;

-In some instances a lack of access to all of your medical records may result in delayed care or incomplete course of treatment

-Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information.

By accepting these terms of use you acknowledge that you understand and agree with the following and your signature below indicates that you consent to examination and treatment by Drexel University CNHP professionals virtually.

Signature*