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Please note: we currently have openings for new patients. Please complete this form to sign up for a free phone consultation with the dietician to determine what dietary and nutrition services may benefit you!
Request Consultation with Dietician/Nutritionist
I understand that this form is to request an appointment with the Registered Dietician. I understand that all Dietician and Nutrition services are self-pay.
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I Agree
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Indicates required field
Contact Name
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Please enter the name of the person we should contact to schedule an appointment. This should be the name of the client or the name of the legal guardian.
Email
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Phone Number for Contact
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Please provide the best telephone number to reach you to schedule an appointment, if an appointment is available.
What are the best days/times to contact you?
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Contact is:
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Adult seeking services
Legal Guardian of a child seeking services
Healthcare Provider seeking referral
May we leave a voicemail at this number?
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Yes
No
Age of Client
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What is the age of the person for whom you are seeking services?
What is your primary concern?
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General Nutrition
Sports and Fitness
Autism Spectrum or Food Phobia
Eating Disorder
Maternity or Post-Natal Nutrition
Other
Please indicate your main concern - we know your concerns may be complicated or that you may have more than one. However, this will give us an idea who might be a good fit for you or your child.
Who referred you to WellSpring? (if applicable)
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Thank you for your request! If an appointment may be available, we will contact you within 5 business days to discuss options. Please be aware that, while we try to respond to every request, due to the high volume of requests, we may not be able to respond in cases where no appointments are available. Thank you for your understanding!
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