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