Client Forms - D-Signed Nutrition

Click Here for Pre-Consult Questionnaire Printer Version

Client PreConsultation Form

Name(Required)

First Name Last Name

Phone(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

D.O.B(Required)

Sex(Required)

Male

Female

1. Please list any previous medical diagnoses, conditions, and eating related challenges.

2. Please list any allergies/sensitivities to foods, vitamins, or medication.

3. Please list any medications you are currently taking.

4. Please list any supplements you are currently taking.

5. Please list your most pressing health concerns & symptoms.

List conditions, aches & pains, gut symptoms – in order of importance. (A – being the most pressing)

6. Please list any health goals/nutrition support you would like to achieve.

i.e. Symptom relief, tips for healthy snacks, cooking recipes, reading food labels, restaurant menu ideas.

7. Please list any labs tests done within the last 12 months and/or any specialty labs.

How did you hear about us?

Do you have any recent labs?

Yes

Questionnaire Submission Date:

LAB TEST ORDERING POLICY

Click Here for a printable version

X/Twitter

This field is for validation purposes and should be left unchanged.

At D-Signed Nutrition, we want you to feel informed and supported throughout the testing process. The following guidelines explain how laboratory testing is ordered, paid for, and reviewed through our office.

1. LAB TESTING IS PATIENT- PAY

Insurance information will not be included on the laboratory order.
Payment for testing must be made in advance.
Payment is made directly to the laboratory, not to D-Signed Nutrition.
D-Signed Nutrition does not markup laboratory testing. You pay the cost charged by the laboratory.
Any questions regarding test cancellation or refunds should be directed to the laboratory.

2. LAB TESTING FEES DO NOT INCLUDE A NUTRITION CONSULTATION FEE

The cost of laboratory testing does not include an appointment to review and interpret your results.
Once your results have been processed, they will be sent to our licensed practitioner portals.
We will notify you when your results are available so that you can schedule a consultation for review, interpretation, and treatment recommendations.
The fee for your nutrition appointment will be collected on the day of your visit.

3. LAB RESULTS ARE RELEASED DURING A CONSULTATION REVIEW

To help ensure that your results are properly understood and placed in the appropriate context, our office reviews laboratory results with you during a consultation.
Many of the specialty tests we recommend require a licensed practitioner to order them. For this reason, completed results are sent directly to the ordering practitioner.
We believe that simply providing test results without professional explanation or a treatment plan can create unnecessary confusion. Our goal is to help you understand what your results mean and what, if anything, they may indicate for your individual care.
Results may be released to you shortly before your scheduled appointment so that you have an opportunity to review them and prepare any questions you may have.

4. LAB TESTING IS AVAILABLE TO ESTABLISHED D-SIGNED NUTRITION PATIENTS

D-Signed Nutrition orders laboratory testing only for individuals who are established patients.
We understand that you may want to help a friend or family member access specialty functional health testing. However, we encourage friends and family members who are interested in testing to schedule a consultation with D-Signed Nutrition.

Patient Name

Patient / Responsible Party Signature

Date

Client PreConsultation Form

LAB TEST ORDERING POLICY

Ready To Begin? Your health journey starts with one conversation Whether you're making a complex diagnosis or simply want to optimize you health, we're here to help you find answers - and the path forward.

D-Signed Nutrition

Ready To Begin?
Your health journey starts with one conversation
Whether you're making a complex diagnosis or simply want to optimize you health, we're here to help you find answers - and the path forward.