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Name
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First
Last
Email
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Phone
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How would you like us to contact you?
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Text
Phone Call
ZIP / Postal Code
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ZIP / Postal Code
Age Group
Child
Teen
Adult
Senior
Child/Teen's Date of Birth
Child / Teen's Name
First
Last
How did you first hear about Sensibly Sprouted?
Referred by a Healthcare Provider
Social Media or Word of Mouth
Online Search, Insurance Directory, or AI
How did you first hear about Sensibly Sprouted?
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Select one…
Referred by a Healthcare Provider
Social Media or Word of Mouth
Online Search, Insurance Directory, or AI
What would you like help with?
Weight Gain
Weight Loss
Kidney Health
Type I Diabetes
Type II Diabetes
Plant Based Nutrition
Heart Health
High Cholesterol
High Blood Pressure
Sports Nutrition
Pediatric Nutrition
Anti-Inflammatory Nutrition
GI Issues
General Wellness
Body Image
Active Eating Disorder (Diagnosed)*
*Please Explain:
Would you prefer in-person or telehealth (video) sessions?
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If you want to get started as soon as possible, choose Telehealth.
Bellingham
Seattle
Smokey Point
Telehealth
Are there any specific goals you would like to work on with your dietitian?
Would you like us to call your insurance to maximize your benefits?
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Yes, please!
I’d prefer to pay cash.
Upload a Copy of Your Insurance Card (Front & Back)
Drop files here or
Select files
Accepted file types: jpg, jpeg, heic, heif, png, pdf, Max. file size: 6 MB, Max. files: 2.
Please upload clear images of the front and back of your insurance card. This will help us verify your benefits faster and ensure a smooth onboarding process. We maintain strict HIPAA-compliant security measures to protect your information.
Would you prefer to manually input your information?
Yes
Insurance
*
Please select one
Aetna
Anthem
Asuris
Asuris Northwest Health
Cigna
Federal Employee Plan
First Choice
HMA
Kaiser
LifeWise
Medicare
Meritain
Moda Health
Out-of-State BCBS
Premera
Regence
TRICARE
United
Other…
What is the name of your insurance?
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Is this is a Washington Exchange insurance?
This is a Washington Exchange insurance.
Member ID (please include any Alpha Prefix)
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Group Number
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Date of Birth
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Do you have another insurance to add?
Yes, I would like to add my secondary insurance.
No, this is the only insurance I will be using.
Other Insurance
*
Please select one
Aetna
Anthem
Cigna
Federal Employee Plan
First Choice
HMA
Kaiser
LifeWise
Medicare
Meritain
Out-of-State BCBS
Premera
Regence
United
Other…
What other insurance do you have?
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What is your other Member ID? (please include any Alpha Prefix)
*
What is your other Group Number?
*