Please check the service or services you are interested in with quantity desired. Be sure to include your insurance information at the bottom of this order form. We will bill your insurance company for the services that are covered, and send you a PayPal invoice for your copay and any other services that are not covered by insurance.

Please contact us directly about In-Office services that are covered by insurance.

Please note our office policy:
A minimum of 48 business hours or two business days (excludes Saturday and Sunday) is required for cancellation or rescheduling of all 1 hour scheduled appointments. A minimum of 24 business hours or one business day (excludes Saturday and Sunday) is required for cancellation or rescheduling of all ½ hour scheduled appointments or you will be charged a cancellation fee. For in-office consultations, full payment is expected at the time of service, unless other arrangements have been made. For phone and e-consultations, payment must be made in advance, unless other arrangements have been made.

Fields with “?” are required.
Insurance
Eligible
Services

Which services or
products are you
interested in?
e-Consultation Services: Quantity
Initial Nutrition Evaluation and Consultation
Comprehensive Nutrition Education
Nutrition Counseling – Follow Up
Nutrition Check-Up
Initial Nutrition Evaluation and Consultation plus Computerized Menu Analysis (Combo Package)
Computerized Menu Analysis, with
30 minute e-Consultation
Phone Consultation Services:
Initial Nutrition Evaluation and Consultation
Comprehensive Nutrition Education
Nutrition Counseling – Follow Up
Nutrition Check-Up
Initial Nutrition Evaluation and Consultation plus Computerized Menu Analysis (Combo Package)
Computerized Menu Analysis, with
30 minute Phone Consultation
Other
Services

These services are not
eligible for insurance
coverage or discount.
Heart Healthy Cookbook
$18.95 (plus shipping & hanndling)
Email Support
$50/month
Menu Development: 3 day menu
$95
Menu Development: 7 day menu
$199
Menu Development: 14 day menu
$350
Computerized Recipe Analysis and Modification
$25 per recipe
Insurance Information

Please provide your insurance information, even if we already have it.

Patient’s Name:

Name of Insured:

Insured’s relationship
to Patient (if not same):

Your Email:

Your Phone Number:
( )
Patient’s Birthdate:

Birthdate of the
Insured (if not same):

Subscriber or Member
ID Number:

Group Number:

Health Insurance Company
and Type of Insurance:
(PPO, HMO, POS, etc.)

Specialist Co-Pay:
(You can find this on
your insurance card.)
$
Toll-free Phone Number
of Insurance Company:
( )
Reason for Visit:
Home Zip Code: