New Patient Forms

Please fill out our New Patient Form.  Press Submit when finished.

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Patient Information

Patient's Full Name:

Date of Birth:

Sex: MaleFemale

Marital Status:

Street Address/Apt#:

City, State, Zip:

Home Phone:

Cell Phone:

Ok To Leave Voicemail: YesNo

Work Phone:

Patient's Employer:

Best Form of Contact: HomeCellWork

Email Address:

Receive Monthly Newsletter?: YesNo

Insurance Information

Primary Insurance

Insurance Plan Name:

Relationship to Insured:

Policy ID:

Group #:

Subscriber Name:

Subscriber Date of Birth:

Secondary Insurance(if applicable)

Insurance Plan Name:

Relationship to Insured:

Policy ID:

Group #:

Subscriber Name:

Subscriber Date of Birth:


Collection of all copay, self-pay and out of network deductible amounts is expected at time of service.


Physician Information

Who Referred You to Our Office?:

Primary Care Physician:

Primary Care Physician Phone Number:

HIPAA

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 info@riverfrontnutrition.com 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.

I have reviewed the HIPPA privacy policy on the website. YesNo

Signed:

Date: