Emily Sucher | SimplePractice

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Someone else

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Reason for care

What is the reason for seeking care?

For example: PCOS, Diabetes, Insulin Resistance, Weight management, Gut Heath, etc.

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Administrative

Referral source

How did you hear about Live Well Dietitian?

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Billing & Payment

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Insurance details

Who is the primary insurance holder? And Date of Birth? Is there a secondary insurance?

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Insurance card upload

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Client Preferences

Preferred appointment times

Morning Afternoon Evening No preference

Is there anything that the practitioner should know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.