• 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.
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  • 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

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  • 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