Nutrition Therapy
Are you interested in nutrition counseling services? Please complete the following questionnaire so we can help you!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
What is your age? (We only treat clients ages 18 and up)
*
Our registered dietitians will be providing telehealth services only. You will have the option to do secure video sessions or phone sessions.
*
I understand
Please indicate your insurance. If you do not see your insurance listed, you will need to pay out of pocket for services.
*
Regence Plan
Premera
Kaiser Permanente
First Choice Health
Paying out of pocket only
Out of network provider - will seek reimbursement
I live in:
*
Washington
Oregon
Registered Dietitians are not able to diagnose medical conditions, so you may need a referral from your doc so insurance will cover your services. Select which applies to you currently:
*
I have a referral already
I can get a referral prior to treatment
I am not able to get a referral
Please let us know your goals for seeking treatment with a registered dietitian. This will help us match you with the best provider.
*
Please indicate your provider preference:
*
Wendy Ellison, RD
Abby Douglas, RDN
No Preference
What is your availability for scheduling appointments (check all that apply):
*
Monday
Tuesday
Wednesday
Thursday
Friday
Early/mid morning
Afternoon
Evenings
Any time will work!
How should we contact you for scheduling?
*
Email
Phone Call
Text
Submit
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