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(704)734-5223


Hours: 8:30 AM - 2:30 PM; Mon - Fri
Saturdays, twice a month

Forms

Paperwork Needed for Initial Visit

Enrollment Form Complete and submit online:
https://mntsurveys.azurewebsites.net/enrollmentsurvey.aspx?praid=NutritionCounselingServices28086

Three-Day Food Record Please complete an online three-day food record using: https://www.myfitnesspal.com/.  Please bring your username and password to your visit so we can access your information.

Office Forms

1. HIPAA Notice – Please review our HIPAA Notice of Privacy Practices You will be offered a copy when you come for your visit.

2. Acknowledgement of Receipt – Please click on this link: Acknowledgement of Receipt of Notice of Privacy Practices. Please download, complete, and bring to your visit.

3. NCS Your Privacy & Permissions – Please click on this link: NCS Privacy & Permissions. Please download, complete, and bring to your visit.

4. Policies and Procedures Form – Please click on this link: Policies and Procedures.   Please download, complete, and bring to your visit.

5. Medical Release Form – Please click on this link: Authorization to Release of Information.   Please download, complete, and bring to your visit.

 

Additional Forms Which May Be Requested After Initial Visit.  You will be instructed to complete these if needed.

1. Food Frequency Assessment
https://mntsurveys.azurewebsites.net/FoodFrequency.aspx?praid=NutritionCounselingServices28086

2. Medical and Health History (Profile 100)
https://mntsurveys.azurewebsites.net/PersonalAndFamilyHistory.aspx?praid=NutritionCounselingServices28086

3. Lifestyle and Eating Habits Survey (Profile 200)
https://mntsurveys.azurewebsites.net/NutritionAndEatingAssessmentSurvey.aspx?praid=NutritionCounselingServices28086