Sandy Kipp RDN

Registered Dietitian Nutritionist and Certified LEAP Therapist

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  • About
  • Services
    • Nutrition Counseling
    • Food and Chemical Hypersensitivity
    • Chronic Disorders
  • Blog
    • Caring for Your Immune System in Times of Crisis
    • Food Sensitivities – what they are and why they can be causing havoc to your health.
    • Figuring Out the Elusive Food Sensitivity
    • Food Chemical Sensitivities
    • Which Diet is Right for You?
    • What’s a Macro?
    • What’s a Carb?
    • The Healing Nature of Bone Broth
    • Why Eat Fruits and Veggies?
    • Why the Digestive System Is So Important
    • Thanksgiving Survival Guide
    • Weight Loss by Ketogenic Diet?
  • FAQ
  • Patient Forms
    • New Patient Form
    • Symptom Survey
    • Food Journal
    • Patient Acknowledgement
  • Contact Sandy
    • Privacy Policy

New Patient Form

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  • Welcome to the road to better health. I am delighted to be on this journey with you! Here are a few details as we move toward your nutrition consultation:

    Please complete this form prior to your consultation, along with the other forms listed under Patient Forms. Please attempt to include one weekend and one weekday in the food journal if possible.

    I am an insurance provider with Blue Cross, United Healthcare, Regence, Select Health, and Medicare and will submit your claim on your behalf. Please call your insurance prior to your appointment to check if dietary counseling is part of your specific plan; specifics on how to do this were sent to you in the New Patient Paperwork email. I offer a discounted rate for private pay which is $120 per hour, and is payable by cash, check, credit card, or health savings plan, and due at the conclusion of our appointment. For other insurances, upon request, I can provide you a receipt to submit to your insurance provider for potential reimbursement.

    If you are a Medicare recipient, I will also have you sign an Advanced Beneficiary Notice (ABN) at the time of your appointment. This ensures that even if your diagnosis is not covered by Medicare, the claim can be submitted for payment to your secondary insurance. If you would like to read this form prior to your appointment, please click here.

    If you have any questions, feel free to contact me.

    I look forward to working with you!

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Click "+" to add more
    NamePhone 
  • I am a provider with Blue Cross, Regence, United Healthcare and Medicare insurances. If you have one of these, please call ahead for coverage of dietary counseling. If needed, please call your doctor's office and ask them to fax (888.972.6280) your "diagnosis code" to my office either as a referral or on letterhead. If you are over 65 and have United Healthcare we must acquire preapproval prior to your appointment. If this is the case, please contact me now as we may need to reschedule your appointment.
    Provider NamePolicy Number
  • Health Goals

  • Medical History

  • 1 - Very Unhealthy2345 - Very Healthy
  • (women only)
  • (use "+" to add more)
    Medication/SupplementDoseFrequencyReason 
  • Family History

  • (click "+" to add more)
    Family memberCondition 
  • Readiness Assessment

  • 1 - Not Willing2345 - Very Willing
    Significantly modify your diet
    Engage in regular physical activity
    Modify your lifestyle (work demands, sleep, exercise)
    Keep a record of everything you eat
    Practice relaxation techniques
    Take supplements for nutrition therapy
    Have a lab test performed for a health assessment
  • Lifestyle Information

    Exercise

  • (click "+" to add more)
    ActivityType/Intensity (low-moderate-high)# Days Per WeekDuration (minutes) 
  • Sleep

  • 1 (Poor)2345 (Great)
  • Social

  • Stress

  • 1 - Low2345 - High
    Work
    Family
    Finances
    Health
    Other
  • Environment

  • Nutrition and Digestion Information

  • This field is for validation purposes and should be left unchanged.

Phone: 208-250-0836
Fax: 888-972-6280

Facility Address
232 2nd Street South
Nampa, Idaho 83651

© 2021 Sandy Kipp RDN
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