NEW PATIENT REGISTRATION FORM

NEW OFFICE PATIENT INFORMATION FORM

In order to make an appointment, please complete the form below. We will check your insurance benefits for nutrition counseling and get back with you to schedule an appointment. Thank you!
Patient's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Reason(s) for Consult (Please describe why you would like to see a Dietitian)*
What day(s) of the week works best for you?
What time(s) of day works best for you?

MorningAfternoonEvening
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail Address*
Sex*
Marital Status

MarriedSingleWidowedDivorced
Phone Number*
CellHome
Emergency Contact *

First NameLast Name
Phone Number*
Relationship to Patient*
Name of Physician

First NameLast Name
Physician's Number
Physician's Address

Street Address

Street Address Line 2

CityState

Zip Code
Please read the statements below.

1. INDIVIDUAL’S FINANCIAL RESPONSIBILITY
- I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service, payable by cash or check.
- Co-payments are due at time of service.
- If my plan requires a referral, I must obtain it prior to my visit.
- In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.
- If I am uninsured, I agree to pay for the medical services rendered to me at time of service.
2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS

I hereby authorize and direct payment of my medical benefits to Dietitian Appointment on my behalf for any services furnished to me by the providers.

3. AUTHORIZATION TO RELEASE RECORDS

I hereby authorize Dietitian Appointment to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

4. LATE CANCELLATION/NO SHOW

I understand that appointments must be cancelled 24 hours in advance. I agree to pay a fee of $50 for any appointments I miss or cancel with less than 24 hours’ notice.
By signing below, you are declaring that you have read the statement above and that you agree to the terms and conditions.
Signature of Patient, Authorized Representative, or Responsible Party*

Clear
Signature of Patient, Authorized Representative, or Responsible Party
Date of Signature*

MonthDayYear
Date
Name of Patient, Authorized Representative, or Responsible Party*

First NameLast Name
Relationship to Patient*
Front of Insurance Card*

Upload a File

Cancelof
Back of Insurance Card*

Upload a File

Cancelof
Name of Primary Insured*
Date of Birth of Primary Insured*

MonthDayYear
Date
Should be Empty:

NEW OFFICE PATIENT INFORMATION FORM