New Patient Intake FormPlease fill out the information below prior to your appointment. Patient Information Name * First Name Last Name Date Of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * How did you hear about us? * Physician Google Social Media Healthcare Website (ex Web MD, Healthgrades) Family member/Friend Insurance Provider Portal/Website Referral Do You Have A Referral? * Yes No Referring Primary Care/Specialist: Primary Care Primary Care Physician If different than the one listed above Primary Insurance Plan Type PPO HMO MEDICARE MEDICAID Primary Insurance Primary Insurance ID # Secondary Insurance Plan Type PPO HMO MEDICARE MEDICAID Secondary Insurance Secondary Insurance ID# Please provide a brief description of the reason for your visit: * Please attach a copy of your insurance and ID below. Our office verifies insurance coverage prior to your appointment. I understand patients are required to provide at least 24- hour notification if an appointment needs to be rescheduled or cancelled. A "No-Call, No-Show" appointment will be subject to a $25 Cancellation fee. * I Agree Thank You!We look forward to seeing you at the time of your appointment. Please send any additional information to admin@lasvegasdietitians.com
