It's Easy!

1. Choose Your Dietitian
2. Fill Out a Pre-Session Form
3. Schedule Your Appointment

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Pre-Session Form
Important notice for Medicare patients: After you fill out this form, you will be prompted to register your customer account and schedule your appointment. It will not cost you any money to schedule your appointment but be aware that we need your physician's referral faxed to us prior to the appointment. It may be faxed to 818-757-3599. Please allow up to 3 days (excluding holidays) for us to acknowledge your referral.

When you arrive at your appointment, you will also be required to bring a valid insurance card and your supplementary insurance card if applicable in addition to your driver's license or state identification card. We will need these to make copies for our records.

Please bring copies of your most recent lab results or ask your doctor to
fax them to us prior to your first visit. Lab results may be faxed to 818-757-3599. Please bring any blood glucose (sugar) results and your glucometer if you are testing your own levels.

For all patients:

You will be required to sign and date your completed pre-session form which your dietitian will provide you with when you arrive for your appointment.

Please fill out the pre-session form to better assist your dietitian before your appointment. This will save you time and ensure you have more time to speak to the dietitian about your concerns. Please make sure you have selected your dietitian before filling out this form. Unless you are a Medicare patient, be aware that forms that are filled out without payment will not be processed! Payments and appointment scheduling are done through our scheduling software - you will be prompted to schedule your appointment after you fill out this form. If you need any assistance or have any questions you may also call us at 1-800-980-9780 during normal business hours.

Note: The form you are about to fill out is for scheduling appointments for home, office, phone, email, or grocery shop with the dietitian appointments "only."

If you have chosen Meal Plans or Diet Analysis, please, click here to fill out a Dietary Recall Form. This form is different from the presession form and you will not be required to schedule an appointment for this service but you will be prompted to register a customer account and purchase the service through our scheduling software's shopping cart.

If you have chosen Supplement Review, please, click here to fill out a Supplement Review Form. This form is different from the presession form and you will not be required to schedule an appointment for this service but you will be prompted to register a customer account and purchase the service through our scheduling software's shopping cart.
 
Dietitian:
Please select the dietitian you want to schedule an appointment with. Note: If you are a returning customer and your medical or health information has not changed since your last appointment, you do not need to re-fill out this presession form. Your dietitian will have your forms on record. If you are a returning customer doing a followup appointment and your information has changed but is not related to a serious medical condition (example: mild weight loss or gain), you may inform your dietitian at your session to save time and they will update your medical record. If you do not know which dietitian you want to schedule an appointment with, you may click here (opens new window) to select from our various dietitians to see which one meets your needs.
  
Please Select the Service You Have Paid For:
Please select the service you will be selecting after filling out the presession form. Note: If you have chosen a supplement review, please click here to fill out our supplement review form. If you have chosen a diet analysis or meal plan, please click here to fill out our dietary recall form. Please note, for these services, you do not have to schedule an appointment but you will be prompted to register your customer account and pay for this service through our scheduling software's shopping cart. If you chose the Grocery Shop With the Dietitian service, please provide the address of your grocery store in the next field.
  
Grocery Shop With the Dietitian Service Only: Address of Grocery Store:
Please provide the full address of the grocery store you wish for the dietitian to meet you at only if you have chosen the Grocery Shop With the Dietitian service. Note: Nutradvice nor its dietitians will be held responsible for inaccurate addresses. If you provide an inaccurate address, we will not be held responsible for your dietitian not showing to the appointment and you will be charged for the service. If the address provided is inaccurate, we will make an attempt to call you but any additional time it takes the dietitian to meet you as a result of a bad address will be factored into your appointment time.
  
Full Name:
E-Mail Address:
Please enter your email address. The email address you provide will be used to schedule your appointment.
  
Verify E-Mail Address:
Referred By:
Referral (if other):
Street Address:
City:
State:
Zip Code:
Phone Number:
Note: If you are planning to schedule a phone consultation, the number you list will be the number we call you at. For phone consultations, we will call you during the time of your appointment. If you are not available we will try 5 minutes later. If you do not pick up after 5 minutes, your appointment will be canceled and you will be charged.
  
Age:
Gender:
  Female
 Male
Marital Status:
  Single
 Married/Partner
Occupation:
Insurance Patients ONLY: Primary Insurance Information:
In the field below, fill out your Policy Holder Name, Social Security Number of the Policy Holder, Policy Holder Birthdate, Your Relationship to the Policy Holder, and the Policy Holder Employer (if any).
  
Insurance Patients ONLY: Secondary Insurance Information (if applicable):
In the field below, fill out your Policy Holder Name, Social Security Number of the Policy Holder, Policy Holder Birthdate, Your Relationship to the Policy Holder, and the Policy Holder Employer (if any).
  
Insurance Patients ONLY: Patient Agreement:
You must agree to the following Patient Agreement before your appointment is authorized. You may be required to sign a copy of your completed pre-session form (which your dietitian will have) as verification of this agreement.
    I authorize insurance payments to be sent to Nutradvice if applicable.
 I certify that I am financially responsible for all services rendered to me and/or members of my family, If insurance does not reimburse Nutradvice.
 You must have your doctor send a referral to us prior to your first visit. Referrals may be faxed to 818-757-3599
 You must bring your current insurance card on your first visit and bring any new cards issued to you for any subsequent visit.
Privacy/Terms of Use for ALL Patients:
Please be sure to read our Privacy and Terms of Use Policy and our HIPAA Patient Privacy Policy.
    I have read and understood Nutradvice's Privacy Policy.
 I have read and understood Nutradvice's HIPAA Privacy Policy.
 I am aware that I can download the policies from Nutradvice's website at any time.
 For all present and future appointments: I will respect my nutritionist’s time by arriving on time for my appointment and be prepared to leave on time.
 Please record the date and time of your appointment. You will be charged for the full amount of your appointment if you miss your appointment or if you do not cancel your appointment 48 hours prior to your scheduled time.
 All outstanding balances will be billed to you. Late fees will be incurred after 30 days. Your account will be sent to collection if not received in 90 days and will include any collection fees and late fees you have incurred.
Height:
You may enter your height in any format that makes you comfortable. Examples: "5 feet 9 inches", "160cm", "62 inches, etc...".
  
Weight:
You may enter your weight in any format that makes you comfortable. Examples: "210 pounds", "82 kg", "190 lbs, etc..."
  
Do you smoke?:
  Yes
 No
Exercise:
Do you exercise? How often? Please explain your typical exercise habits if any.
  
Medications:
Are you on any medications?
    Yes
 No
Medications (continued):
If yes, please name the medications and dosages of any medications you are using. Also describe the reasons you are taking each medication.
  
Patient Medical History:
Do you have any previous medical conditions (not current)? Example: former smoker, history of hypertension, past surgeries, injuries, etc...
  
Family Medical History:
Does your family have or had any medical conditions? Example: family history of high cholesterol, mother has osteoporosis, family history of obesity, etc...
  
Current Medical Conditions:
Do you have any current known medical conditions?
    Yes
 No
Current Medical Conditions
(continued):
If yes, please list any current known medical conditions that you have.
  
Are You Having Any of the Following Problems?:
(Check all that apply)
    Difficulty chewing
 Difficulty swallowing
 Nausea
 Vomitting
 Constipation
 Diarrhea
 Mouth sores
Are You Having Any of The Following Problems? (continued):
Please elaborate on the above problems you checked, if any (Example: You have dentures or you experience nausea after eating certain foods).
  
Allergies:
Do you have any known allergies?
    Yes
 No
Allergies (continued):
If yes, please list known allergies and symptoms.
  
Supplements:
Are you currently taking any over the counter drugs or supplements (vitamins, calcium, herbal extracts, etc...)?
    Yes
 No
Supplements (continued):
If you are taking any over the counter drugs or supplements, please list them below and why you are using them. Please list the brand (if known) and amount taken.
  
Special Diets:
Have you been following any special diet(s) at home (Example: Atkins, Southbeach Diet, etc...)?
  
Food preferences/likes and dislikes:
Do you have any dietary preferences (Example: Vegetarian/Vegan, Kosher, will only eat chicken or fish, do not like certain foods, etc...)?
  
Discussion:
What would you like to speak to your dietitian about? Note: If you requested an email consultation, please ask your 5 questions here. Your dietitian will respond directly to you from their Nutradvice email address. Email consultation questions are meant to be simple and brief. This is how we keep the price low. The responses your dietitian will give you will be no more than 2 paragraphs in length per question asked with no followup responses unless you feel the dietitian was not clear. If your question(s) asked requires more in-depth discussion, your dietitian may request that you set up an office, phone, or at-home consultation. Follow-up or new questions may be asked if you paid for 2 email consultations and may be responded directly to the dietitian's email address instead of filling out a new presession form so long as your information has not changed since you last asked your questions. Once you have completed your presession form, your dietitian will email you directly back with their responses to your questions.
  
Verify Image:
Nutradvice prevents automatic submissions in order to serve you better. Please type the numbers you see in the image on the left into the box below.
  
Congratulations!
You did it! You're one step closer to acheiving your goals! All of us at Nutradvice wish you the very best and thank you for trusting us to help you with your health and nutrition needs.
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