BRG Dietetics & Nutrition, P.C.

Please check the service or services you are interested in with quantity desired. Be sure to include your insurance information at the bottom of this order form. We will bill your insurance company for the services that are covered, and send you a PayPal invoice for your copay and any other services that are not covered by insurance.

Please contact us directly about In-Office services that are covered by insurance.

Please note our office policy:

A minimum of 24 hours is required for cancellation or rescheduling of all appointments. For in-office consultations, full payment is expected at the time of service, unless other arrangements have been made. For phone and e-consultations, payment must be made in advance, unless other arrangements have been made.

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Which services or products are you interested in?	e-Consultation Services:
	Initial Nutrition Evaluation and Consultation	Qty:
	Comprehensive Nutrition Education	Qty:
	Nutrition Counseling – Follow Up	Qty:
	Nutrition Check-Up	Qty:
	Initial Nutrition Evaluation and Consultation plus Computerized Menu Analysis (Combo Package)	Qty:
	Computerized Menu Analysis, with 30 minute e-Consultation	Qty:
	Phone Consultation Services:
	Initial Nutrition Evaluation and Consultation	Qty:
	Comprehensive Nutrition Education	Qty:
	Nutrition Counseling – Follow Up	Qty:
	Nutrition Check-Up	Qty:
	Initial Nutrition Evaluation and Consultation plus Computerized Menu Analysis (Combo Package)	Qty:
	Computerized Menu Analysis, with 30 minute Phone Consultation	Qty:

These services are not eligible for insurance coverage or discount.	Heart Healthy Cookbook $23.95 each (includes sales tax and S&H)	Qty:
	Email Support $30/month	Qty:
	Menu Development: 3 day menu $75	Qty:
	Menu Development: 7 day menu $165	Qty:
	Menu Development: 14 day menu $295	Qty:
	Computerized Recipe Analysis and Modification $25 per recipe	Qty:

Please provide your insurance information, even if we already have it.
Patient's Name:
Name of Insured:
Insured's relationship to Patient (if not same):
Your Email:
Your Phone Number:		()
Patient's Birthdate:
Birthdate of the Insured (if not same):
Subscriber or Member ID Number:
Group Number:
Health Insurance Company and Type of Insurance: (PPO, HMO, POS, etc.)
Specialist Co-Pay: (You can find this on your insurance card.)		$
Toll-free Phone Number of Insurance Company:		()
Reason for Visit:
Home Zip Code:

The evidence is mounting that soy is protective against heart disease, some cancers, osteoporosis and helpful in relieving symptoms of menopause. Soy products are derived from the soybean, which contain all of the building blocks of protein as well as iron, folic acid, calcium, magnesium, potassium, and the B vitamins. Whole soybeans are the base of foods like tofu, soy nuts, soymilk, soy flour and tempeh.

Find out what “lowfat”, “light”, “reduced-fat” and other food-labeling terms really mean! Food-labeling definitions for 12 common terms can be found in this informative cookbook.

Find out more!