Patient Forms

Welcome to Shira Evans Nutrition LLC. I look forward to working with you to help you achieve your nutrition-related goals. The following guidelines have been established to facilitate our work together. Please feel free to ask any questions, as I am here to meet your needs.

Office Forms

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Office Policies

Confidentiality Policy

Your privacy is very important, and all sessions will be held in strict confidence. A release form will be used to obtain permission to speak with your physician and/or other healthcare providers regarding your treatment. You are not required to sign the release.

Billing and Insurance Coverage Policy

Payment is due before the time of service or immediately following services and will be charged by a HIPAA-compliant platform called Ivy Pay®. Credit, debit, HSA and FSA cards are acceptable forms of payment. A receipt can be provided for services rendered. Shira Evans Nutrition LLC does not accept insurance at this time but can provide you with a monthly Superbill that you can submit to your insurance company. Insurance companies may
or may not cover nutrition counseling.

Cancellation and Refund Policy

Time has been specifically reserved for your nutrition appointment. If you need to cancel or reschedule your appointment, please do so by contacting Shira Evans Nutrition LLC via e-mail or phone with a minimum of 24-hours notice from your appointment time. Appointments not canceled within this time frame will be charged at 100 percent. Your cooperation with this policy is greatly appreciated.

Lateness Policy

Appointments will be held for 15 minutes only. If you arrive within this time period, you will be seen but your appointment time will not be extended. After 15 minutes, your appointment will be forfeited, and you will be charged 100 percent of the session fee (if prepaid, a refund will not be given).

Your signature below indicates that you understand and agree to the Office Policies.

Patient Name(Required)
Parent/legal guardian if the patient is under 18 years of age.