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Nutrition Counseling Forms

Thank you for choosing Nutritional Weight & Wellness for your nutrition counseling appointment! Every day we see nutrition improve the lives of our clients, and we look forward to seeing what nutrition can do for you.

Your initial appointment will last one and a half hours.

Privacy Practices

Review our Notice of Privacy Practices to learn how your protected health information may be used and disclosed.  Your privacy is important to us. You can be assured that we are committed to protecting and safeguarding your privacy. 

Health Questionnaire Forms

Please fill out our health questionnaire and submit the form as soon as possible. You have three options:

  1. Submit Forms Electronically: For security reasons, forms must be completed in one sitting. You will have 60 minutes to complete each page. You will have the option to print a PDF of your forms after you click the "submit" button.

    Regular - clients that pay at the time of service or Nutrition 4 Weight Loss clients
    Access Regular Forms

    Insurance clients
    Access Insurance Forms
    Make sure to call your insurance company and ask about coverage.

  2. Forms Mailed to You: Call 651-699-3438 to have the forms mailed to you.
    If possible, please return the form before the day of your appointment. You can (1) fax the form to 651-695-0191, (2) drop the form off, or (3) mail the form to one of our locations.

  3. Print Forms: Click the appropriate link below to access a PDF of the health questionnaire that you can print on your own:
    Regular Forms - clients that pay at the time of service or Nutrition 4 Weight Loss clients
    Insurance Forms- insurance clients
    Make sure to call your insurance company and ask about coverage. 

ON THE DAY OF YOUR APPOINTMENT

  • Please arrive at least five minutes prior to the scheduled time of your appointment. If you are late, your appointment will be shortened.
  • Bring any prescription medications or supplements you are currently taking, as well as any lab results you would like to discuss.
  • Please refrain from wearing perfume or cologne as many of our clients are sensitive to scents.
  • Regular Initial clients: please note that payment is due in full at the time of your appointment.
  • Nutrition 4 Weight Loss Program clients: payment is not required at the time of your appointment since you already paid for the program and your counseling appointment is included in the program cost.
  • Insurance clients: payment is not required at the time of your appointment.  Your claim will be sent in to your insurance provider and you will be billed for co-pays and/or deductibles.

INSURANCE COVERAGE

If you have questions about coverage, please visit our FAQ page or call us at 651-699-3438.

Notice of Privacy Practices

This notice describes how your protected health information (PHI) may be used and disclosed by Nutritional Weight & Wellness

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