Intake Form

New Patient Intake with Janelle Smith Nutrition:

Thank you for scheduling with me for nutrition counseling. I'm looking forward to working with you on your nutrition goals.

Please complete this form ahead of your appointment to give us more time in session. This form is double password protected in compliance with HIPAA regulations.

Sincerely,
Janelle

General Information

* Indicates required field

Patient name *

Date of birth *

Email *

Phone *

Billing address (with zip code) *

Would you like a superbill for our visits? A superbill can be used for accounting for Health Savings Accounts, tax credits, and/or reimbursement from health insurance plan under out-of-network benefits. *

No thank you Yes, after each individual visit Yes, in a bulk superbill after multiple visits

Acknowledgment of cancellation policy: Please give 24 hours notice for cancellation or rescheduling. I will charge the full fee for sessions that are missed without this notice. Appointments can be self-changed within Calendly via a link in the calendar event and email reminder. You may also email, text, or call me to notify me of the change. *

Yes, I acknowledge. I will give 24 hrs notice to change or cancel appointments. I understand I will be charged for missed sessions without 24 hrs notice.

Health Information:

Height *

Weight (approximate) *

Current medications (prescription and over the counter): i.e. Name of medication (dose) and frequency *

Medical and psychiatric diagnoses: *

Nutrition Information:

What does a typical day of eating look like? Sample format: Breakfast (time): Lunch (time): Dinner (time): Snacks (times): Beverages: *

What are your goals for nutrition counseling? *

Submit