Follow-up Nutrition Appointment Reminder & Checklist

Transcription

1 Follow-up Nutrition Appointment Reminder & Checklist scheduled with. Appointment Date: Appointment Time: New Cancellation Policy: We require three business days notice for cancellations. A cancellation with less than three business days will be charged 50% of the scheduled appointment fee. For Example: If appointment is: Monday Tuesday Wednesday Thursday Friday Cancel by: Wednesday by 3 pm Thursday by 3 pm Friday by 3 pm Monday by 3 pm Monday by 3 pm Forms: (Complete and Return Prior to Your Appointment) Medication/Supplement List (it may be a good idea to enter these into a word processing document to update easily in the future) Medical Symptoms Questionnaire Diet Diary: (For one day. If you track your diet electronically (iphone app or online tool), please print out a day or two of your records) Fats and Oils Worksheet Challenges, Successes, Questions and Goals BIA Assessment: (Review Attached Handout for Preparation Instructions) See the enclosed summary to prepare for a re-measure of your body composition using the BIA. Feel free to bring a snack/food with you for after the BIA. Lab Results: If you have received lab orders, test results from your lab work take 3 weeks to get to us. Your follow-up consultation is dependent on us receiving your lab results. Questions: If you have any questions, please contact one of our patient service representatives: Nancy Lynn or Crystal Lowe Patient Service Representatives

2 Medication/Supplement List How many times and at what ages have you taken Infancy Childhood Teen Adulthood Antibiotics Steroids Include non-prescription drugs as well as vitamins, minerals, and other nutritional supplements. Indicate the mg or IUs and the form (e.g. calcium vs. calcium lactate) when possible. Supplements / Medications Dose Units Frequency Start Date Stop Date

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6 Challenges, Successes, Goals & Questions I look forward to seeing you again! In order to help you best achieve your nutrition and health goals, it s important to monitor your progress. The following forms will help determine your current nutrition status. Be as honest as possible, so we can effectively meet your goals! Please complete the questions below and enclosed documents for the upcoming nutrition appointment: List barriers or challenges you faced throughout the last several weeks or months: List changes that you re pleased with (e.g. symptom changes; weight or inches lost; increasing or decreasing a certain food in your diet; other successes ): List your goals and/or expectations for this appointment: List any questions you have today:

7 Services Pricelist Physician Services New Patients Established Patients 60 minutes: $ minutes: $ minutes: $ minutes: $ minutes: $ minutes: $ minutes: $ minutes: $300 Phone Consults 15 minutes: $75 30 minutes: $ minutes: $200 Nurse Practitioner/Physician Assistant Services New Patients Established Patients 60 minutes: $ minutes: $ minutes: $ minutes: $ minutes: $ minutes: $ minutes: $ minutes: $255 Phone Consults 15 minutes: $63 30 minutes: $ minutes: $170 Nutrition Services New Patients/Established Patients/Phone Consults 15 minutes: $25 75 minutes: $ minutes: $45 90 minutes: $ minutes: $85 BIA Testing: $25 Neurofeedback Services Initial consult or physician referral required prior to treatment Two hour Neuromapping: $400 Neuromap Reading (by Brain Science International): $350 Neurofeedback, per session: $150 Neurofeedback (Package of 10): $1,350 Phone Consults 30 minutes: $75 60 minutes: $150 Infusion Services Initial consult and patient s G6PD blood test results must be received prior to vitamin C infusions 0-30 minutes: $ minutes (Package of 10): $ minutes: $ minutes (Package of 10): $1, hours: $ hours (Package of 10): $1,440 >3 hours: $200 Injection, singular substance: $25 Injections, 2 or more substances: $30 Financial Responsibility: Please be aware that services rendered are the financial responsibility of the patient. Payment in full is due at the time of service. We do not accept or file insurance of any sort. Prices do not include lab test costs. New Cancellation Policy: We require three business days notice for cancellations. A cancellation with less than three business days will be charged 50% of the scheduled appointment fee.

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