Deprecated: Function create_function() is deprecated in /var/www/wp-content/plugins/madang-plugin/custom/setup.php on line 72
New Patient Intake Form – LBS Nutrition LLC
Notice: Undefined property: EasyColumns::$use_custom in /var/www/wp-content/plugins/easy-columns/easy-columns.php on line 233

New Patient Intake Form

Please fill in the form below so we can learn more about you.

Click here for a print-friendly version.

Patient Information


Tell Us More About You


When You're at Home...

What Did You Eat Yesterday for...

Your Biggest Food Craving:*


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 $35 missed appointment fee out of pocket.

Floating Review Template1
  • I recently had my first session with Sari and I am beyond pleased with my experience! I am very excited to be on this journey to wellness and I feel more confident in succeeding now that I have a wond... Read More
  • I am very satisfied with LBS Nutrition. Everyone is wonderful very polite and professional. Julie is amazing scheduling the appointments and always available to assist. I love how Sari takes the time ... Read More
  • Sari was absolutely amazing!!!! Not only did she explain everything to me, she made sure she emailed me everything we chatted about. She even answered an email I sent her on the weekend! I am so happy... Read More
  • The staff and Lauren are kind and helpful. I’ve done many weight loss programs without success but LBS creates a non stressful method catered to your individual needs and goals that really works. I... Read More
  • I’ve had just 2 sessions with Sari Greaves so far and I could not be happier! My journey for weight loss will truly begin in August 25th and so far Sari has been helping me get in the mind set befor... Read More