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. Client Name
* How did you hear about A Little Nutrition? * Email *
Home Phone * Work Phone Cell Phone Date Of Birth Month - Date - Year (MM-DD-YYYY) * We have a mulitple locations and office settings. Please check off where would you like to have your appointment?
Choose more than one if multiple preferences.
What time of day would you like your appointment?
Choose more than one if you have more availability.
Do you want to get in to meet with a dietitian immediately, or in the next few weeks? If you have a preference or a specific date or time that you would like for your appointment, please indicate below. 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. What appointment type are you interested in? Weight Loss Coaching 1x time nutrition assessment or consult Diabetes or cholesterol help Digestive Help Food allergies Prenatal/postnatal Family Nutrition Craving Change(TM) Meal Planning Rescue Grocery Store Tour Vegetarian/Vegan nutrition assessment 1-Week Meal Plan Nutrigenomix Not sure yet Section Break SECTION A HOW CAN WE HELP YOU WITH YOUR NUTRITION? What is your primary reason for meeting with a dietitian nutrition coach? Please list any medical known conditions Are you taking any medications or antidepressants? If yes, please list the names and dosages Is there anything you would like to share or feel that your dietitian should know prior to your appointment to assure a successful partnership? 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 Check all that apply: Health & Wellness Check all that apply: Family Nutrition Topics Check all that apply: Lifestyle & Mindful Eating Check all that apply: Would you like to receive our free weekly meal plans & meal planning inspiration newsletter? Section Break SECTION B Medical Insurance Information -
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, If you do not have insurance, pls. skip to the end and press SUBMIT 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. Are you the primary policy holder? (Is this your insurance plan or is it your partners?) What company is your primary insurance plan with? I am not submitting insurance information Blue Cross Great West Life Chamber of Commerce Sirius Benefits Green Shield Claim Secure Other If "other" what is the medical insurance company name?
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. Employer/company name: Primay Policy Holders First & Last Name
Primary Policy Holders Date Of Birth Month - Date - Year (MM-DD-YYYY) Group/Plan/Policy /Firm#: Contract / ID#/ certificate#: 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 What insurance company is your second plan with? To coordinate, it must be the same as the primary plan. Employer/company name: 2nd Payer -Policy Holders First & Last name
Primary Policy Holders Date Of Birth Month - Date - Year (MM-DD-YYYY) 2nd Payer- Group/Plan/Policy /Firm#:
Second Payer -Contract / ID#/ certificate#: