This inquiry form is not HIPPA compliant. By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Sunrise Nutrition harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means. If you prefer, you may call us to share your Protected Health Information. Ph: 316.217.2984. Our text system is not HIPPA compliant.
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Client Name (Parent / Guardian info will be entered below)
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Parent / Guardian info will be entered below.
First Name
Last Name
Client Phone (Enter n/a if minor with no phone)
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Parent / Guardian Phone will be entered below
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Can we text this number? (Please note our text system is not HIPPA compliant.)
Patient is
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If under 18 years, please enter Parent or Guardian's email address for paperwork purposes:
If under 18 years, please enter Parent or Guardian's phone number:
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Can we text the parent / guardian at this number? (Please note our text system is not HIPPA compliant.)
Where did you hear of Sunrise Nutrition?
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If applicable, please enter the name of the person who referred you or the location of the presentation you attended. Thank you!!
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My preferred appointment location(s) (Please select all that apply.)
If you selected more than one location preference, please explain.
I live in
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Will you seek services even if insurance tells you they won't cover nutrition counseling?
(If yes we'll schedule you in the first available slot. If no, please schedule far enough out so that you can check your benefits before scheduling. You are responsible for costs insurance does not cover. We will provide you an insurance verification form with the exact questions to ask!)
Comments
Who is your insurance company? (We DO NOT verify benefits. This is YOUR responsibility. Please do not assume nutrition counseling is covered. We can look some plan coverage up online if you ask!)
What employer is your insurance through? (ex. Wichita Public Schools, City of Wichita, etc.)
Which of these fits you best?
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What else would you like us to know about your needs?
Our occasional (sometimes bi-monthly) newsletter is meant to encourage you in your food peace journey, not to clutter up your inbox (we hate that too!). If you'd like to have your email added please indicate below:
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In order to schedule an appointment, Sunrise Nutrition requires a credit card on file. I understand that my credit card will be automatically charged a late cancellation / no show fee of $80 if I cancel within 24 hours or do not attend my scheduled intake session. This card will also automatically be charged for any balance insurance does not pay. If you have any questions about this, please contact us.
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If Sunrise Nutrition is unable to serve you, would you like us to forward this request to a provider who fits your needs?
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