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Nutri-Wellness LLC
Home
NUTRITION
ABOUT
MY STORY
AREAS OF EXPERTISE
SESSIONS
PATIENT
INSURANCE ACCEPTED
NEW PATIENT FORMS
PRACTICE POLICY
HIPAA
Credit Card on File Agreement
FAQ
Elena's Blog
TESTIMONIALS
Pay Now
Contact
PATIENT
INSURANCE ACCEPTED
NEW PATIENT FORMS
PRACTICE POLICY
HIPAA
Credit Card on File Agreement
Please COMPLETE ALL QUESTIONS BEFORE YOUR APPOINTMENT
THE New Patient HISTORY
Form BELOW
Press Submit when you HAVE finished
NUTRI-WELLNESS LLC
1200 Route 22 East,
Suite 2000
Bridgewater, NJ 08807
Tel.908-377-4744
NEW PATIENT NUTRITION HEALTH HISTORY FORM
Name
*
First Name
Last Name
Date of Birth
*
SEX
Male
Female
MARITAL STATUS
*
Married
Single
Other
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home phone
*
(###)
###
####
Cell phone
*
(###)
###
####
Email
*
Reason for visit
*
How do you know about us ?
*
Date and time of appointment
*
INSURANCE INFORMATION
Primary health insurance name
*
Policyholder First and Last name
*
Policyholder DOB
*
Insurance ID card number
*
Relationship to insured
*
Secondary health insurance name if applicable
*
Policyholder First and Last name
*
Policyholder DOB
*
Insurance ID card
*
Primary care Physician Name
*
Primary care Physician phone
*
Preferred method of contact
*
NUTRITIONAL HISTORY
Has your weight changed in the past 3-6 months ?
*
YES
NO
What is your weight ?
*
What is your height ?
*
Have you seen a DIETITIAN / NUTRITIONIST before ?
*
Do you currently follow eating plan ?
*
Please indicate any food and /or drug allergies:
*
Past Medical History (please check-off all that applies to you):
Heart Attack
High Blood Pressure
Arrhythmia
Gastritis
Inflammatory Bowel
Celiac Disease
Diarrhea
Nausea /Vomiting
Irritable Bowel Syndrome
Diabetes
Low blood sugar
Anxiety
Depression
Dementia
Depression
Kidney Disease
****** Please keep in mind that there is a $50.00 cancellation fee if you cancel with less than 48 hours in advance.
******Credit Card on File Agreement - Effective June 17,2021 Nutri- Wellness LLC has implemented a new credit card policy. Recent changes in health markets and payment processes have altered insurance coverages to shift the cost of care to our patients.
******The credit card information will be obtained at your initial visit and kept confidential and secure until the insurance(s) has paid their portion. If your medical insurance does not cover your nutrition consultation, then Nutri-Wellness LLC automatically charges your debit/credit card. Also, if the patient did not follow the 48 hours cancellation appointment policy, Nutri-Wellness LLC will charge $50.00 for the missed appointment. Invoice for outstanding balance will be sent to the patient via email or mail letter.
*********** I authorize Nutri-Wellness LLC to keep my debit/credit card on file and to charge my debit/credit card for any outstanding balances that my health plan has identified as my financial responsibility. If the provided debit/credit card has changed, expired, or denied for any reason, I agree to immediately give Nutri-Wellness LLC, valid debit/credit card, which I will allow to be charged over the phone. I agree that the new card will be used with the same authorization as the original card I presented.
CARDHOLDER NAME
*
First Name
Last Name
Email
*
DEBIT/CREDIT CARD NUMBER
*
EXPIRATION DATE
*
CVV
*
ZIP CODE
*
CHOOSE CREDIT CARD
Select
Visa
Master Card
Discover
American Express
SIGNATURE CARDHOLDER
*
DATE
*
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