Kathy Levine MS, RD, CDN
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Children's Registration and Nutrition Assessment Form

Either download and print registration/nutrition assessment form and bring to initial visit
OR fill out digital form below.

    Patient Information


    Child Nutrition Assessment

    How much of the following are consumed per day?



    Please read the following information carefully. Clicking the "I agree" checkbox indicates your responsibility for this account and your guarantee of payment of all charges as they accrue. It is your responsibility to verify that your insurance plan covers your diagnosis for nutritional counseling.

    • I agree to reimburse you for office visits if insurance company doesn't pay.
    • I will pay for missed appointments unless I give 24 hours notice or it is a true emergency. Please note: insurance doesn't cover missed appointments. You will be responsible for paying my usual fee.
    • I authorize Kathy Levine to exchange records and information with my physician.

    For office use only:

Submit

Goldens Bridge Office Building
​100 North County Shopping Center
Suite 203
PO Box 223
Goldens Bridge, NY 10526   

 Phone: (914) 767-0734
Fax: (914) 232-8537
rdklevine@gmail.com