Health Investment Through Proper Nutrition - Angela Lemond, RD, CSP, LD
Patient Forms
Prior to your appointment, please fill out the following forms ahead of time and bring them with you:
 
ADULT PATIENTS
Patient History
Food Logging instructions (only if Angela requests; she will set you up with a login)
Insurance Information (if insurance is being used for services rendered)
HIPAA Statement (Print for your records only)
Medical Release & HIPAA signature
 
Other items that would be helpful for a more complete nutrition assessment include laboratory results completed in the last 6 months and any medical records pertinent to the reason for the appointment.  Fax those to 888-821-2292 or bring those items with you.
 
PEDIATRIC PATIENTS
Pre-appointment Questionnaire
Food Logging Instructions (only if Angela requests; she will set you up with a login)
Insurance Information (if insurance is being used for servcies rendered)
HIPAA Statement (Print for your records only)
 
Other items that would be helpful for a more complete assessment include historical growth charts from the primary care or specialty physician, laboratory results completed in the last 6 months and any other medical recoreds pertinent to the reason for the appointment.  Fax those to 888-821-2292 or bring those items with you.  For small children being seen, forms and records faxed ahead of time will allow the appointment to go quicker and more efficiently.
 
Insurance Information (if insurance is being used for services rendered)
HIPAA Statement (print for your records only)
Medical Release & HIPAA Signature (one for each family member)
 
Other items that would be helpful for a more complete assessment include historical growth charts (for children under 18) from the primary care or specialty physician, laboratory results completed in the last 6 months and any other medical recoreds pertinent to the reason for the appointment.  Fax those to 888-821-2292 or bring those items with you.