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Fill out our HIPAA-protected Nutrition Check-In form below. We’ll reach out within two business days to connect you to your dietitian.

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"*" indicates required fields

Name*

First Last

Phone*

How would you like us to contact you?*

Text

Phone Call

Email*

ZIP / Postal Code*

ZIP / Postal Code

Age Group

Child

Teen

Adult

Senior

Child/Teen's Date of Birth

MM slash DD slash YYYY

Child / Teen's Name

First Last

What would you like help with?

Active Eating Disorder (Diagnosed)

Body Image

Weight Gain

Weight Loss

Kidney Health

Type I Diabetes

Type II Diabetes

Plant Based Nutrition

Heart Health

High Cholesterol

High Blood Pressure

Sports Nutrition

Pediatric Nutrition

Anti-Inflammatory Nutrition

GI Issues

General Wellness

Would you prefer in-person or virtual sessions?*

In-person

Virtual

Location

Bellingham

Seattle

Smokey Point

Are there any specific goals you would like to work on with your dietitian?

Would you like us to call your insurance to maximize your benefits?

Yes, please!

I’d prefer to pay cash.

Insurance*

What is the name of your insurance?*

Member ID (please include any Alpha Prefix)*

Group Number*

Date of Birth*

MM slash DD slash YYYY

Do you have another insurance to add?

Yes, I would like to add my secondary insurance.

No, this is the only insurance I will be using.

Other Insurance*

What other insurance do you have?*

What is your other Member ID? (please include any Alpha Prefix)*

What is your other Group Number?*