Please fill out our New Patient Form. Press Submit when finished.
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Patient's Full Name:
Date of Birth:
City, State, Zip:
Ok To Leave Voicemail: YesNo
Best Form of Contact: HomeCellWork
Receive Monthly Newsletter?: YesNo
Insurance Plan Name:
Relationship to Insured:
Subscriber Date of Birth:
Who Referred You to Our Office?:
Primary Care Physician:
Primary Care Physician Phone Number:
I acknowledge that I have been provided an opportunity to read your Notice of Privacy Practices, which is available to view on the website, www.riverfrontnutrition.com. I can request the Privacy Practices to be mailed to me. A request can be made by emailing firstname.lastname@example.org or by calling 201-880-9400.
I acknowledge that I am responsible for payment if my medical insurance does not cover the services provided by Riverfront Nutrition Associates.
If I am a Medicare patient with a condition covered by Medicare I acknowledge that Medicare is my primary insurance.
I understand that Riverfront Nutrition Associates has an office policy whereby I will be charged a $25 fee upon my failure to provide 24 hours notice of cancelling an appointment. By signing below, I am agreeing to comply with this policy and, if I do not, I am agreeing to pay the fee as stated previously.