New Patient Registration Form Your Contact InformationFirst Name *Last Name *Phone NumberDate of Birth *Email Address *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeInsurance InformationInsured Policy Holder's Name / Self *Insured Policy Holder's Date of Birth *Insurance Card FrontChoose FileNo file chosenDelete uploaded fileIf you have it, please upload a picture of the front of your insurance card.Insurance Card BackChoose FileNo file chosenDelete uploaded fileIf you have it, please upload a picture of the back of your insurance card.Primary Care Physician (PCP) *Referred By *Payment MethodTo keep on file, your card will not be charged at this time.Credit Card Number *Expiration Month *0 / 2Expiration Year *0 / 2Security Code *Billing Zip Code *0 / 5Signature: Sign your name with your cursor or finger here. *Your browser does not support e-Signature field.I request that authorized insurance benefits are paid on my behalf to LBS Nutrition LLC for services rendered to me. Additionally, I authorize any holder of medical information about me to release it to our office for the rendering of services and the processing of insurance billings. I certify that all the information provided by me on this form is true and accurate. I have received/reviewed the HIPPA Privacy Notice of this office and hereby guarantee, acknowledge responsibility for, and will assume payment of all charges against this account as they accrue. This includes agreeing to pay the $50 missed appointment fee out of pocket. Send Message
