New Patient Forms
Intructions:
- Click on the links below, type right onto the form and then save the forms to your computer. On forms that require a signature, your typed name is acceptable as your signature.
- Email the completed forms (attach them as PDFs) to Bonnie@BRGHealth.com prior to your appointment.
- If your appointment is in person, you may print and bring the forms with you to the office at your scheduled appointment time.
NOTE: If the patient is under 18 years of age, please compete the Pediatric Nutrition Assessment Form in place of the Medical History Form. All other forms MUST be completed.
For Individual Nutrition Counseling
Patient Registration
Medical History
Pediatric Nutrition Assessment
Informed Consent Form
Office Policy
Privacy Practices Acknowledgement
Click here to view HIPAA Policy
For Group/Family Nutrition Counseling
Family Nutrition History Questionnaire (plus Informed Consent, Office Policy and Privacy Practices Acknowledgment forms above)
Can’t read PDFs? Download Acrobat Reader software for free here.
“I’ve been working with Bonnie for a few months now and I feel great! After years of dieting and struggling with my weight, I’ve come to realize that losing weight is much easier than I ever imagined it would be. I learned that dieting is not the answer and that the key to success is simply a combination of exercise and learning how to eat healthy. Thank you Bonnie for guiding me to a healthier lifestyle and for showing me the way to success. Slow and steady wins the race!”
—Rebecca, West Hempstead, N.Y.