• New Client Appointment Form

    The following questionnaire is intended to help us gain a full understanding of your nutrition needs and get you set up with one of our dietitian nutrition coaches. If you want to direct bill your appointment, please fill out our Medical Insurance information at the end of this form.
  • Date Of Birth
    Choose more than one if multiple preferences.
    Choose more than one if you have more availability.
  • Please note that most of our coaching and counselling packages are a fee for service and start at $125 per 1-hr session. We do offer direct billing to medical insurance companies, see below.
  • Section Break

  • SECTION A

  • Choose the topics you would like to discuss with your dietitian. This will help us plan your sessions and ensure all of your nutrition questions are answered!

  • Food Topics

  • Health & Wellness

  • Family Nutrition Topics

  • Lifestyle & Mindful Eating

  • Section Break

  • SECTION B

  • Medical Insurance Information -
    If you do not have insurance, pls. skip to the end and press SUBMIT

    If you would like to use your medical insurance to pay for your appointment, please fill out the following information. Note: We can only direct bill if your plan allows direct billing. Companies like Sunlife, Manulife, Empire Life, Co-operators & Desjardins do not allow direct billing. If you have insurance with these companies, you will have to pay upfront and submit your claim after your appointment. 
  • We probably haven't worked with this company yet, so we will do our best to get set up to direct bill for you, however that is only if your plan allows.
  • PLEASE NOTE: If you are a dependent on the plan, please provide the primary policy holders FIRST & LAST NAME. If this is your plan, you can leave name and Date of birth blank.

  • Primary Policy Holders Date Of Birth
  • Co-ordination of  Benefits

    If you have two plans with the same insurance company, we would be happy to coordinate benefits. The second payer *must be the same insurance company as primary. Ex. Blue Cross & Blue Cross or GWL & GWL . We can not coordinate benefits with different insurance companies.
  • Medical Insurance Plan Numbers

  • Primary Policy Holders Date Of Birth
  • Section Break

  • SECTION C

  • APPOINTMENT RESERVATION & CANCELLATION POLICY

    Your appointment time is reserved just for you. To secure your appointment we require a valid credit card number to hold your appointment. Your credit card number will be stored in our secure credit card vault hosted by PayFirma and is heavily encrypted. You may call into our office (204-792-1893) to give us your credit card number, or our office manager will call you to obtain it.

    Your appointment is not fully booked in our system until we have a credit card on file. Your credit card will not be charged until the time of your appointment, and if you choose to use an alternate form of payment you can do so. We accept, cash, cheque, e-transfer in addition to credit card payments.

    A late cancellation or missed visit leaves a hole in the dietitians' day that could have been filled by another client. As such, we require 24 hours notice for any cancellations or changes to your appointment. Clients, who provide less than 24 hours notice, or miss their appointment, may be charged a cancellation fee of $45.

    All appointments must be cancelled via phone at 204-792-1893.

     

    INFORMED CONSENT FORM & TERMS FOR NUTRITIONAL COUNSELING

    I am hiring the counselling/consulting services of A Little Nutrition Registered Dietitians (RD). The appointment will provide information and guidance about health factors within my own control: my diet, nutrition, and lifestyle in order to nourish and support my health and wellness. 

    I understand that A Little Nutrition employs Registered Dietitians (not a medical physician) and does not dispense medical advice, nor will they diagnose or treat any medical condition.

    I understand nutrition counselling is not a substitute for the diagnosis, treatment, or care of disease by a medical provider, but will provide nutritional support and nutrition education for an already diagnosed condition.

    Rather, they provide education to enhance my knowledge of health as it relates to foods, dietary supplements, and behaviours associated with eating. While nutritional support can be an important compliment to my medical care, I understand these services are not a substitute for medical care.

    I understand that A Little Nutrition will keep chart notes as a record of our work together. These notes document the topics that we talk about, interventions used, and treatment plan or any other considerations that may be helpful to your work with me.

    Records will be stored in an encrypted online system designated for work. Medical records, personal information and history divulged in session to the dietitian will be kept strictly confidential unless I consent to sharing my medical and nutritional information with collaborating practitioners.

    Electronic systems used for teleconferencing will incorporate network and software security to protect the confidentiality of the client. I understand that the benefits and risks from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my dietitian, that the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. 

    In order to benefit from nutrition counselling, I realize that it is important for me to inform my physician or A Little Nutrition of any changes I make in the application of my diet. It is my responsibility to report any side effects or problems immediately and to make the necessary adjustments to my treatment plan with my physician and/ or A Little Nutrition. I will not hold A Little Nutrition responsible for any complications that result from my failure to comply with either of the above. 

    I agree to hold A Little Nutrition & its staff harmless for claims or damages in connection with our work together. This is a contract between myself and A Little Nutrition and I understand that it is also a release of potential liability. 

     

    By checking this box and submitting this form, I acknowledge I have read, had the opportunity to ask questions, and agree with the consent form above. I am aware of the Appointment Reservation & Cancellation Policy.