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NEW PATIENT PAPERWORK

Upon completion, please email to southbloomfieldnutrition@gmail.com.

NEW PATIENT INTAKE FORM

Please fill out and submit at least 48 hours prior to your scheduled appointment. Not submitting before means less time for your appointment or appointment being rescheduled.

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Note: If you would like forms mailed to you, please inform Rebecca.

2-DAY FOOD LOG (OPTIONAL)

Please fill out and submit before your appointment. It is better to fill out as the day goes by rather than guessing at the end of the day! Try to be as specific as possible. (Ex: 1 cup green beans with 1 Tbsp butter)

LEGAL AGREEMENTS

The following documents will be reviewed and signed at the start of your first visit. It is encouraged to review them before your visit.

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-HIPAA Notice of Privacy

-Advanced Notice, Patient Financial Responsibility, and Cancellation Policy

-HIPAA Information Release Authorization (Not Required)

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