Enrollment Survey

Lifestyle Medicine Group

*Required

Name

First	M.I.	Last
*Required *No Special Characters		*Required *No Special Characters

Date of Birth  *Required *Valid Date of Birth Required (format MM/DD/YYYY)

Gender at birth
(select one) Male Female *Required

Address
Line 1 *Required
Line 2

 City
*Required

State
--- AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY *Required

Zip
*Required *Valid US Zip Code Required

Phone
*Required *Valid Phone Number Required

Fax
*Valid Fax Number Required

Email
*Valid Email Required

Marital Status
(select one) Single Married Other *Required

Employment Status
Full-Time Part-Time Not Working/Retired

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Physician

First	M.I.	Last
*Required		*Required

Phone
*Valid Phone Number Required (or leave blank)

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

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Insurance Carrier

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

Phone
  *Valid Phone Number Required (or leave blank)


Health Insurance ID Number
*Required

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Have another Insurance Carrier?

Yes

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Are you a dependent?

Yes

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

 Yes

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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 *Required *Valid Name Required
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.