Insurance Inquiry Form

Patient Name

Parent Name [if applicable]

Phone Number

Date of Birth of Patient

Address of Patient

Preferred Dietitian [if any]

Preferred Office: Morehead City or New Bern

Primary Reason for Visit [or click below]

Primary Reason for Visit [select all that apply]

Peak Performance
General Wellness / Healthy Eating
Weight Loss
Health Concerns: Diabetes
Health Concerns: High Cholesterol / High Blood Pressure
Health Concerns: Gastric Issues [Food Allergies, Crohn’s, IBS, Ulcerative Colitis]
Menopausal Health
Bariatric Surgery [Gastric Bypass/Sleeve/Band]

Primary Insurance Name

Birth Primary

Primary Insurance ID#

Primary Insurance Group #

Secondary Insurance Name

Secondary Insurance Group #

Questions or Comments