Scheduling a Bariatric Nutrition Follow-Up with Dietitian Nancy Lum RD, LDN

Scheduling a Follow-Up Appointment with Dietitian Nancy Lum

This form is to only be used for scheduling your a follow-up appointment with Nancy Lum, RD, LDN. If you are looking to schedule other services please contact our office. https://nutrition5.com/contact-us/
Please select ONE*

PATIENTGIBNC STAFF

FOR STAFF USE ONLY
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FOR PATIENT USE

"Existing" means that you have seen a dietitian in this practice in the past 18 months. If it has been more than 18 months please email us on https://nutrition5.com/contact-us/
Are you an existing* patient of The GI and Bariatric Nutrition Center*

YESNO

You have indicated that you have not seen one of our dietitians in the past 18 months or are seeking other services than a 30-minute follow-up. This requires special scheduling, please contact our office regarding scheduling at 443-490-1240 or email us at www.nutrition5.com/contact-us

If this is a mistake click on the "back" button below.

Follow-Up Appointment Terms and Limitations:
1. Follow-Up services are for existing* patients of The GI and Bariatric Nutrition Center. *If you have not seen a dietitian with our office in more than 18-months, you are considered a new patient.
2. We are limited to discussing no more than 1 issue during a single follow-up appointment. More than this will require multiple visits.
3. This form is for follow-ups only, if you feel you need to discuss more than 1 issues with the dietitian please contact our office, as this may constitute multiple appointments. (Examples: we can discuss your recent weight gain or plateau at your appointment. We are unable to discuss the gain/plateau and your carb counting/diabetes, or pregnancy, or thyroid, etc. during one 30-minute appointment. Discussing the diabetes, pregnancy, thyroid, etc. would require separate appointments.)
4. This will be a telemedicine appointment.
5. There is an out-of-pocket expenses for this service. We will collect the payment for this appointment today, at the time of scheduling. We accept all major credit cards.
By agreeing below you agree to the terms of our follow-up appointments*

AGREEDISAGREE

You have indicated that you disagree with the terms and limitations of our follow-up appointments. Please contact our office www.nutrition5.com/contact-us

If you answered incorrectly on the "back" button below.

You have indicated that you disagree with our missed appointment policy.

Please contact our office https://nutrition5.com/contact-us/

If you feel that you answered incorrectly please click on the "back" button below.

You have indicated that you need dietary assistance regarding a new diagnosis/condition.

Please contact our office regarding scheduling. www.nutrition5.com/contact-us

If Other above, please explain the reason for your follow-up. *
What type of non medically necessary diet are you wanting guidance on? *
I understand that I must complete my mindful eating log no less than 3 business days prior to my follow-up appointment and by not doing so my appointmnet may be rescheduled. https://form.jotform.com/GIBNC/mindful-eating-log-for-follow-ups*

Yes, I agree to complete the mindful logOther

If "Other" vitamins/ brand please describe below.*
Please list any current medical diagnosis, if none say NONE. *
Please list any current prescriptions and/or over the counter medications you are taking, if none say NONE.*
Do you have any files you wish to share for your appointment?

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Schedule Your Appointment

Please be sure to add your appointment to your calendar, we will send you an invitation to the event through Google Calendar. (HIPAA Compliant)
Select the desired duration for your appointment*

30-Minutes ($65 due today)60-Minutes ($125 due today)
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USDBased on the duration of the appointment you are scheduling, 30 or 60 minutes.

I understand that I will receive a confirmation email from office.communication@gibnc.net and a calendar invitation for this appointment. And that I must accept the invitation to receive reminders.

YESNO
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Scheduling a Follow-Up Appointment with Dietitian Nancy Lum