Clarity — Peace & Power LLC

READY TO BOOK?

For insurance payment: Please fill out questions # 1-5 on this form below.
For private payment: Please provide your contact information and then scroll all the way down to answer question #5.

Name

First Name

Last Name

Email

#1 What is the name of your health insurance?

#2 Do you have nutrition services on your insurance policy? If you have nutrition services are you able to visit with Jennifer Carlson, Registered Dietitian, of Peaceful Nutrition Practice?

#3: Do you need a specific diagnosis to see a Registered Dietitian or can you see a Registered Dietitian for preventative measures/ general wellness? If you do need a diagnosis, please ask your insurance representative if your specific diagnosis is covered.

#4 How many covered visits do you have per calendar year?

#5 Please let me know how I can assist you.

I will be in contact with you shortly via the e-mail address you provided.

Kindly note: My e-mail may, unfortunately, end up going to your spam folder! If you haven’t heard from me, please check this folder.