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Please Print Form and mail it to us with your payment or
you can drop it off at our office.
you can drop it off at our office.
Nutrition at Best: Registration Form for New Patients
Last Name: ________________________________ MI__________ First Name:_______________________________
Date of Birth: _____________ Age: ______ Gender: (Circle) Female / Male *** HEIGHT: ___ WEIGHT: _____
Social Security # __ __ __-__ __- __ __ __ __ Primary Care Doctor:______________________________________
Patient’s Address:___________________________________________________ City:__________________________
State: ___________ Zip Code: _______________________ Email: _________________________________________
Home Phone: (__ __ __)__ __ __-__ __ __ __ Work Phone: (__ __ __)__ __ __-__ __ __ __ Cell Phone: (__ __ __)__ __ __-__ __ __ __
Name of Primary Insurance Company and Subscriber ID#:____________________________________________________
Relationship to the insured: SELF SPOUSE CHILD OTHER
**Please read each policy for Nutrition at Best, Inc. and sign below.
• Nutrition at Best, Inc. has a 24 hour cancellation policy. If you do not call our office within 24 hours prior to your appointment, you
may be responsible for the full amount of your appointment, even though you do not attend the session.
• As a courtesy to our patients that show up on time for their appointment, all patients that are late to their appointment may have to
forfeit any time missed and maybe responsible for the full amount of their appointment.
• Nutrition at Best, Inc. does NOT refund your money for the nutrition class or any nutrition session you attend if you choose not to
have bariatric surgery or if you are not qualified for the surgery.
• Nutrition at Best, Inc. has a $35 returned check fee on all returned checks. Note: Criminal procedures may take place if patient
has a history of this matter, please make sure you have sufficient funds before sending a check.
Bills that are not paid within 90 days will be sent to collections.
• (Class) Payment and registration form must be received 1 week prior to class date or the date specified by Jennifer Elias,
RD, LDN (Dietitian). This will insure a spot for you. (1 on 1 consulting) Payments are due at the time of service.
• I understand that if my insurance does not cover for the nutrition class or session, that I will be responsible for payment.
• It is the responsibility of the patient to read all instructions on all supplements, read all ingredients in all supplements and
contact their healthcare provider in reference to any questions regarding medication or health concerns prior to taking any
supplements. It is also the responsibility of the patient to confirm any and all exercise and nutrition recommendations with
their healthcare provider.
• Nutrition at Best, Inc. may report information about patients in the aggregate but does not release the patient's name without
patient consent. I also give Nutrition at Best, Inc. permission to verify insurance coverage if needed, file and bill accordingly.
• Nutrition at Best, Inc. reserves the right to charge a reasonable fee for any extra copy and fax services.
• I also give permission to Nutrition at Best, Inc to leave a voice mail if needed with the phone numbers I listed above.
• I understand Nutrition at Best, Inc.'s Notice for Privacy Practice. I understand that a copy is available at check in for patients
to review. I understand that I may request a copy of the Notice of Privacy Practice at any time.
• I plan to attend the Nutrition Class for Bariatric Surgery presented by Jennifer Elias RD, LDN –Dietitian. I understand a nutrition
follow up is recommended about 6 weeks after surgery.
• I hereby authorize disclosure of my medical records to Southern Surgical Associates, P.A.
• I agree to be seen as a patient with Nutrition at Best, Inc and agree to the above policies for Nutrition at Best, Inc. To the best
of my knowledge, the information I will share with Nutrition at Best, Inc and its employees is correct.
• At the time of class, if there is a taste test offered or samples available, I participate per my own wishes and do not hold Nutrition
at Best, Inc. liable for anything.
I have read and I completely understand all of Nutrition at Best, Inc. policies as stated above.
Signature: ______________________________________________ Date: ______________________
OFFICE USE:
Last Name: ________________________________ MI__________ First Name:_______________________________
Date of Birth: _____________ Age: ______ Gender: (Circle) Female / Male *** HEIGHT: ___ WEIGHT: _____
Social Security # __ __ __-__ __- __ __ __ __ Primary Care Doctor:______________________________________
Patient’s Address:___________________________________________________ City:__________________________
State: ___________ Zip Code: _______________________ Email: _________________________________________
Home Phone: (__ __ __)__ __ __-__ __ __ __ Work Phone: (__ __ __)__ __ __-__ __ __ __ Cell Phone: (__ __ __)__ __ __-__ __ __ __
Name of Primary Insurance Company and Subscriber ID#:____________________________________________________
Relationship to the insured: SELF SPOUSE CHILD OTHER
**Please read each policy for Nutrition at Best, Inc. and sign below.
• Nutrition at Best, Inc. has a 24 hour cancellation policy. If you do not call our office within 24 hours prior to your appointment, you
may be responsible for the full amount of your appointment, even though you do not attend the session.
• As a courtesy to our patients that show up on time for their appointment, all patients that are late to their appointment may have to
forfeit any time missed and maybe responsible for the full amount of their appointment.
• Nutrition at Best, Inc. does NOT refund your money for the nutrition class or any nutrition session you attend if you choose not to
have bariatric surgery or if you are not qualified for the surgery.
• Nutrition at Best, Inc. has a $35 returned check fee on all returned checks. Note: Criminal procedures may take place if patient
has a history of this matter, please make sure you have sufficient funds before sending a check.
Bills that are not paid within 90 days will be sent to collections.
• (Class) Payment and registration form must be received 1 week prior to class date or the date specified by Jennifer Elias,
RD, LDN (Dietitian). This will insure a spot for you. (1 on 1 consulting) Payments are due at the time of service.
• I understand that if my insurance does not cover for the nutrition class or session, that I will be responsible for payment.
• It is the responsibility of the patient to read all instructions on all supplements, read all ingredients in all supplements and
contact their healthcare provider in reference to any questions regarding medication or health concerns prior to taking any
supplements. It is also the responsibility of the patient to confirm any and all exercise and nutrition recommendations with
their healthcare provider.
• Nutrition at Best, Inc. may report information about patients in the aggregate but does not release the patient's name without
patient consent. I also give Nutrition at Best, Inc. permission to verify insurance coverage if needed, file and bill accordingly.
• Nutrition at Best, Inc. reserves the right to charge a reasonable fee for any extra copy and fax services.
• I also give permission to Nutrition at Best, Inc to leave a voice mail if needed with the phone numbers I listed above.
• I understand Nutrition at Best, Inc.'s Notice for Privacy Practice. I understand that a copy is available at check in for patients
to review. I understand that I may request a copy of the Notice of Privacy Practice at any time.
• I plan to attend the Nutrition Class for Bariatric Surgery presented by Jennifer Elias RD, LDN –Dietitian. I understand a nutrition
follow up is recommended about 6 weeks after surgery.
• I hereby authorize disclosure of my medical records to Southern Surgical Associates, P.A.
• I agree to be seen as a patient with Nutrition at Best, Inc and agree to the above policies for Nutrition at Best, Inc. To the best
of my knowledge, the information I will share with Nutrition at Best, Inc and its employees is correct.
• At the time of class, if there is a taste test offered or samples available, I participate per my own wishes and do not hold Nutrition
at Best, Inc. liable for anything.
I have read and I completely understand all of Nutrition at Best, Inc. policies as stated above.
Signature: ______________________________________________ Date: ______________________
OFFICE USE:
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WEIGHT LOSS HISTORY
Circle the following diets you have used in the past:
Weight Watchers Low Fat Diet
Atkins Low Calorie Diet
South Beach Slim Fast
The Zone LA Weight Loss
Nutria System Jenny Craig
Any others not listed:_____________________________________________________________
MEDICIAL HISTORY
Circle the following that you have been diagnosed with:
High Blood Pressure Back problems
High Cholesterol Stomach Ulcers
Diabetes :Type 1 or 2 Migraines
Anxiety Anemia
Depression Sleep Apnea
Any others not listed:____________________________________________________________________
Do you have a history of any eating disorder, ie. Anorexia or Bulimia ___________________________________________
Please list any current medications you are taking: ____________________ __________________________________
___________________________ _______________________________ __________________________________
___________________________ _______________________________ __________________________________
________Current Weight From past 5-10 years: _________Highest Weight _________Lowest Weight
Are you currently exercising? _______Yes _________No
If yes, how often, how long, and what types? _______________________________________________________________
What is your current occupation? _______________________________ How many hours per week do you work?______
Do you Smoke? _______Yes _________No Do you Drink? _______Yes _________No
If yes to either, How often and how much? ________________________________________________________________
Have you ever been seen by a dietitian before? _______Yes _________No
(Optional)
Martial Status: ______SINGLE ________MARRIED _____ DIVORCED _____WIDOWED How many children ,if any:____
Circle the following diets you have used in the past:
Weight Watchers Low Fat Diet
Atkins Low Calorie Diet
South Beach Slim Fast
The Zone LA Weight Loss
Nutria System Jenny Craig
Any others not listed:_____________________________________________________________
MEDICIAL HISTORY
Circle the following that you have been diagnosed with:
High Blood Pressure Back problems
High Cholesterol Stomach Ulcers
Diabetes :Type 1 or 2 Migraines
Anxiety Anemia
Depression Sleep Apnea
Any others not listed:____________________________________________________________________
Do you have a history of any eating disorder, ie. Anorexia or Bulimia ___________________________________________
Please list any current medications you are taking: ____________________ __________________________________
___________________________ _______________________________ __________________________________
___________________________ _______________________________ __________________________________
________Current Weight From past 5-10 years: _________Highest Weight _________Lowest Weight
Are you currently exercising? _______Yes _________No
If yes, how often, how long, and what types? _______________________________________________________________
What is your current occupation? _______________________________ How many hours per week do you work?______
Do you Smoke? _______Yes _________No Do you Drink? _______Yes _________No
If yes to either, How often and how much? ________________________________________________________________
Have you ever been seen by a dietitian before? _______Yes _________No
(Optional)
Martial Status: ______SINGLE ________MARRIED _____ DIVORCED _____WIDOWED How many children ,if any:____
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