New Patient Intake Form

Complete the new patient intake form prior to your appointment. Our office will verify active insurance coverage and notify you of any out-of-pocket expense prior to your visit. Send any additional information to admin@lasvegasdietitians.com

Patient Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Date Of Birth

YYYY

How did you hear about us?

Referral Information

Do You Have A Referral?

Yes

Most insurances do not require a referral to see a Dietitian. Please check with your insurance for plan specific requirements.

Referring Primary Care/Specialist:

Primary Care Information

Primary Care Physician if different than the one listed above

How often do you get lab work/bloodwork done?

Insurance Information

Missing insurance information may delay the insurance verification process

Primary Insurance

Primary Insurance ID #

Is this a Medicaid Plan?

Yes

Secondary Insurance

Secondary Insurance ID#

Is this a Medicaid Plan?

Yes

Additional Information

Please provide a brief description of the reason for your visit:

I understand patients are required to provide at least 24- hour notification if an appointment needs to be rescheduled or cancelled. A "No-Call, No-Show" appointment will be subject to a $25 Cancellation fee.

I Agree

I understand patients are required to notify Las Vegas Dietitians of any changes in insurance prior to any appointments.

I Agree