Enrollment Survey

Lifestyle Medicine Group

Name

First M.I. Last

Date of Birth  

Gender at birth


Address
Line 1
Line 2

 City


State


Zip


Phone


Fax


Email


Marital Status


Employment Status



Physician

First M.I. Last

Phone


State your reason(s) for seeking Medical Nutrition Therapy:


Insurance Carrier

Name
(If you have no Insurance Carrier enter "N/A")

Phone
 


Health Insurance ID Number



Have another Insurance Carrier?

Yes

Name


Phone


Health Insurance ID Number



Are you a dependent?

Yes

Relationship to Subscriber

Name of subscriber

First M.I. Last

Date of Birth


Gender at birth



Have you had Medical Nutrition Therapy or Diabetes Self Management Training before?

 Yes

If so when


Describe




Comments


I acknowledge that I have read and received the Notice of Privacy Practices. I also authorize the payment of medical and government benefits to my healthcare provider for services received.

Type Full Name
Signature of Patient/Parent/Guardian


By clicking submit I hereby acknowledge that the above information is correct and true to the best of my knowledge.