Please fill out this form prior to your appointment with Michelle Dougherty, RD.
Date of Birth
Primary Contact Number
Alternate Contact Number
Best way to send reminders
Text to primary contact number
Text to secondary contact number
Name of Legal Guardian (if appicable)
Home Phone Number of Guardian
Cell Phone Number of Guardian
E-mail of Guardian
Would you like text or e-mail reminders sent to guardian?
Name of person responsible for bill payment
Doctor's Contact Phone Number
Doctor's Address (please just put town if you do not know the address)
Therapist's Contact Phone Number
Therapist's Address (please just put town if you do not know the address)
Reason for referral
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