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WAITLIST APPLICATION

Please complete this application if you are interested in working with one of our functional nutrition providers. We will contact you as soon as a spot becomes available. 

Click the button below to start.

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Question 1 of 7

I am interested in:

(Select all that apply)
A

1:1 appointment (for myself)

B

1:1 appointment (for a child)

C

Other

Question 2 of 7

Are you interested in enrolling in our group program, The Blood Sugar Blueprint? (Starts January 15th)

A

Yes

B

No

C

I'd like more information

Question 3 of 7

Reasons for contacting (this will help us route you with the dietitian best suited for your needs):

(Select all that apply)
A

Adrenal dysfunction

B

Autoimmune disorders

C

Fertility/Pregnancy

D

Postpartum/Breastfeeding

E

Pediatrics

F

Prediabetes/Diabetes

G

Food allergies/intolerances

H

IBS/IBD

I

Vegan/Vegetarian

J

Thyroid concerns

K

PMS management

L

PCOS

M

Perimenopause/menopause

N

Weight management

O

Other (explain in comments at end of application)

Question 4 of 7

Preferred appointment/scheduling needs:

(Select all that apply)
A

In-person

B

Virtual

C

Appointments before 9am

D

Appointments after 5pm

E

Other specific needs (explain in comments at end of application)

Question 5 of 7

What insurance do you have?

A

BCBS/Anthem

B

UHC/UMR

C

Aetna/Meritain

D

Cigna

E

Paying out of pocket

F

Other (explain in comments)

Question 6 of 7

What state are you located in?

Question 7 of 7

ADDITIONAL QUESTIONS:

1. Phone number (email will be on next slide)

2. For PEDIATRIC applications, list child's name. 

3. Any other questions or comments.

 

**We will follow up within 1 business day of receiving your request. You can call/text 910-408-5338 or email [email protected] with any questions!

Confirm and Submit