Patient Information

Patient Intake Form

Name Age Date of Birth

Social Security Number

Gender Male Female

Marital Status Single Married Divorced Widow/er

Address City State Zip Phone Cell Phone Occupation Employed By Address City State Zip Phone Referred By

Medical Insurance Yes No

Name of person responsible for payment Address City State Zip Phone Cell Phone What medications are you taking now? Allergies Primary Language

Consent for Treatment: I, the undersigned consent to such services as provided by Nutrition Consultants On Demand Corp.

Assignment of Benefits: I (insured), authorize Nutrition Consultants On Demand Corp to bill my Insurance Company and to receive payment directly for services provided by Nutrition Consultants On Demand Corp. I also understand and agree that I am ultimately responsible for the entire payment for the services provided by Nutrition Consultant On Demand Corp in case of default or denial of payment by the above Insurance Company including any payment that may be misdirected to me (which I will endorse to Nutrition Consultant On Demand Corp).

Release of Care Information: I (insured), authorize Nutrition Consultants On Demand Corp, to release information about my care to my insurance company listed above for the purposes of coordinating benefits and payments. I also authorize my insurance company to release information concerning my insurance benefits to Nutrition Consultants On Demand Corp.

I understand that an electronic signature has the same legal effect as a written signature. By checking this box and typing my name below, I am electronically signing this form. E-Signature