Patient Forms

To ensure the highest quality of care and a smooth experience during your visit, all patients are required to complete a set of standard patient care forms prior to their appointment at the Nutrition & Metabolic Health Initiative (NMHI). These forms are essential for establishing care, protecting your privacy, and allowing our team to provide the most personalized and effective services possible.

Forms Include:

• HIPAA Consent Form
  Outlines your rights under the Health Insurance Portability and Accountability Act (HIPAA) and ensures your personal health information is handled with the utmost confidentiality.

Download HIPAA Form

• Consent to Treat
  Authorizes our clinical team to provide evaluation, treatment, and follow-up care as part of your wellness plan.

Download Treatment Form

• Email Communication Consent
  Allows us to communicate with you securely via email for appointment reminders, educational materials, and follow-up care instructions.

Download Email Form

• Telehealth Communication Consent
  Allows us to communicate with you securely via telehealth platforms to conduct remote nutrition consultations.

Download Telehealth Form

• Health History and Intake Forms
  Collect important information about your medical history, lifestyle, dietary habits, and current health concerns to support a personalized care plan.

Download Intake Form

• Authorization to Release and Disclose Patient Information
  Allows us to release and communicate your medical information amongst providers involved in your care.

Download Release Form

• Patient Request for Access of Health Information
  Allows you to obtain a copy of your medical record from NMHI.

Download Access Form

• Authorization for Verbal Release of Protected Health Information (PHI)
  Allows us to discuss patient health information, in person or by teleaphone, with a designated individual you select.

Download Verbal PHI Form

 

These forms are typically completed before your first appointment and may be updated periodically to reflect changes in your health or communication preferences. Completing these forms ahead of time helps minimize delays and ensures your visit starts on time. If you have any questions or need assistance with the forms, please contact our front desk at 806.742.6644 or email us at nmhi@ttu.edu. If you are unable to complete these forms before your service date, please arrive a minimum of 15 minutes before your schedule appointment time to complete the forms.