RISE Consultation Form

Your Name: *

First Name

Last Name

Mobile Phone: *

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Scheduled Appointment Date: *

MM

DD

YYYY

Whose health are you primarily interested in discussing at this visit? *

Yours

Your partner's/spouse's

Your child's (12 or younger)

Your child's (13 or older)

Your whole family's

Please check off the topic(s) you are MOST interested in discussing at this visit: *

We recommend selecting no more than 2-3. We're happy to explore other topics at future visits!

Healthy weight loss

Healthy weight gain

Implementing a vegetarian/vegan diet

Implementing another type of eating style

Getting motivated to make healthy lifestyle changes

Meal planning and prep

Incorporating more physical activity into your life

Fitting healthy habits into a busy lifestyle

Other (please describe below)

For meals outside of work/school hours, which best describes your mealtime routine? *

Our family sits down to eat together

Everyone eats at the same time, but in different areas of our home

Everyone eats at separate times

We usually eat on-the-go (e.g. on the way to or from activities)

Finally, please check the following boxes to confirm your acknowledgment of our policies:

I understand that my visit will not be billed to insurance, and full payment is due prior to being seen by Dr. Parker.

I understand that I am expected to arrive 10 minutes before my scheduled visit, and that a late arrival may shorten my time with Dr. Parker.

I understand that Parker Place requires 48 hours' notice to cancel an appointment, and failure to give 48 hours' notice may incur a no-show fee of $50.