Christine Sloat, MS, RDN, CDN Registered Dietician. Patient Registration Form. Street: Suite/Apt. # Date of Birth: City: State: Zip Code:

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1 Christine Sloat, MS, RDN, CDN Registered Dietician Patient Registration Form Name: : Street: Suite/Apt. # of Birth: City: State: Zip Code: Phone (home): Phone (work): Cell Phone: address: Name of person to call in an emergency: Relationship: Street: Suite/Apt. #: City: State: ZIP code: Phone: Name of person filling out this form (if not patient): Name of Primary Care Physician (PCP): last seen: PCP Office Address: Suite/Apt. #: City: State: ZIP code: Phone: Fax:

2 Insurance Information: Insurance Company: Ins. Phone: Subscriber: ID #: Subscriber s Employer: Birth : Patient s relationship to subscriber: Secondary Insurance Company: ID#: Statement of Release by Patient to Insurance Company I request that payment of authorized insurance benefits be made on my behalf to Christine Sloat, MS, RDN, CDNfor services furnished to me by this practitioner. I authorize Christine Sloat, MS, RDN, CDN to release medical information about me to the applicable insurance company should any information be needed to determine these benefits. Please be advised that only the minimum necessary information will be disclosed to serve these administrative purposes. I acknowledge that the above information I have provided is correct. Patient or Parent/Guardian Signature Witness

3 Nutrition Therapy-New Client Assessment Form Please complete the following form accurately and to the best of your knowledge. Responses will be used in creating the best care plan to addresses your needs, goals and interests. All information will remain confidential. Background First Name Last Name of Birth Gender: (please circle) Male Female Mailing Address: Home Phone: Cell Phone: Address: Medical History: Please indicate whether you or an immediate relative has been diagnosed with any of the following by placing an X in the appropriate box: Condition Irritable Bowl Syndrome Crohn s Disease Ulcerative Colitis Celiac Disease Reflux Heart Disease Stroke High Blood Pressure High Cholesterol Depression/Anxiety Bipolar Disorder ADD/ADHD Eating Disorder Migraines Kidney Stones Type 1 Diabetes Type 2 Diabetes Cancer (any type) Other: Please describe below I have been diagnosed A relative has been diagnosed Please describe any other conditions related to your medical history:

4 Please list any medications you are currently receiving: Please list any vitamins/minerals or herbal supplements you are currently taking: Please list any food or medication allergies you are aware of: Primary Care Physician: of last visit: Phone Number: Have you ever had an appointment with an RD or nutritionist? Yes No Weight History: Current Weight: Current Height: Have you experienced significant weight gain/loss in the past year? Yes No Goals Please indicate the areas in which you are most interested in receiving guidance:

5 Christine Sloat, MS, RDN, CDN 950 New Loudon Rd., Suite 101, Latham, NY (518) AUTHORIZATION FOR RELEASE OF INFORMATION I,, authorize Christine Sloat, MS, RDN, CDN, to obtain from and release the health information described below to: Name Contact Info This request and authorization applies to only the following protected health information: List each purpose or reason for the use or release of the protected health information: This authorization shall remain in full effect until the end of our treatment relationship or it will expire 5 years from today, whichever comes first. I understand that, except with respect to action already taken in reliance on this authorization, I may revoke this authorization in writing at any time by delivering or sending written notification to: Christine Sloat, MS, RDN, CDN, 950 New Loudon Rd., Suite 101, Latham, NY I understand that Christine Sloat, MS, RDN, CDN, may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization, unless my treatment is related to research and the purpose of this authorization is related to the research project. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws. If this authorization is for the release of HIV-related information, the recipient of the information is prohibited from redisclosing any HIV-related information about you without your authorization unless permitted to do so by federal or state law. I understand that I have the right to receive a copy of this authorization after I have signed it. I understand that a copy of this authorization will be maintained in my patient record. I understand that I have the right to refuse to sign this authorization. Patient s signature (relationship if signed by parent / guardian) Witness signature