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. *

Yes, I want to submit this form & agree to the terms of use.

Client Name (Parent / Guardian info will be entered below) *

Parent / Guardian info will be entered below.

First Name

Last Name

Client Phone (Enter n/a if minor with no phone) *

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.)

By checking this box (or texting) you agree to receive text messages at the provided number from Sunrise Nutrition Consulting. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT of receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.

Yes

No

Patient is *

18 years or older

Under 18 years old (We require a parent / guardian fill out payment forms.)

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.)

By checking yes, you agree to receive text messages at the provided number from Sunrise Nutrition Consulting. Standard message and data rates may apply. You have the right to opt out of receiving messages at any time. TO OPT OUT, reply "STOP" to any text message you receive from us.

Yes

No

Where did you hear of Sunrise Nutrition? *

I attended a presentation by Sunrise Nutrition

My Therapist

My Primary Care Provider (doctor/nurse/etc.)

My insurance company

A Friend

Facebook

Instagram

Internet / Google Search

Other

Which of these fits you best? *

I'm seeking assistance for a specific diagnosis such as diabetes or high cholesterol.

I struggle with binge and emotional eating.

I think I might have an eating disorder but I've never been diagnosed.

I'm primarily interested with help for body image, not food.

My child has been diagnosed with anorexia or bulimia.

I have been diagnosed with anorexia or bulimia. (We can provide evaluation & recommendations. We currently do not have treatment slots available for adult anorexia/bulimia. )

None of these apply to me. (Please include below your reason for seeking services.)

I prefer not to answer this question. I'll discuss my situation in my first session & if I need to transfer to a different dietitian based on my need that's okay.

My preferred appointment location(s)

Newton

Telehealth

Newton or Telehealth

After school appointments are limited & usually not available. Does this work with your schedule?

Yes.

Maybe. Please enter a comment below.

No. I'd like to wait until holiday break / summer to be seen.

No. (Please enter comment below)

I live in *

Kansas

Missouri

Oklahoma, Colorado, Washington

Other (please include your location in the message below so we can check licensure requirements)

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!)

No insurance, I plan to self pay.

Blue Cross Blue Shield Federal Plan (Federal Agency Employee)

Blue Cross Blue Shield State of KS Plan (University, School, City / County / State Employees)

Blue Cross Blue Shield Commercial Plan (usually through a private business)

Blue Cross Blue Shield (I'm unsure if it's a federal, state or commercial plan)

KanCare (United Healthcare Medicaid) (ONLY covers for individuals 20 years and younger. NO coverage for adults at this time.)

KanCare (Sunflower or Aetna Better Health) (We are NOT in network with these, you will be cash pay.)

Commercial United Healthcare (UMR, Surest/Bind, Student Resources, etc.)

Cigna

Medicare (Medicare ONLY covers us for diabetes. No other diagnoses are covered. Prediabetes is NOT covered.)

Aetna through Spirit Aerosystems

Aetna/Mertain - NOT through Spirit Aerosystems

Other: Please add your carrier to the message below.

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: *

to the once-in-awhile food peace newsletter

to the group education wait list

please do not add my email to the lists at this time

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. *

Yes, I agree to this.