Appointments / Forms

Making an Appointment
Consults are by appointment only, you can call, email, or fill out the form below. Timeliness is very important for us, we understand your time is valuable, and as such, we expect you to respect our time as well. Please try to be prompt to your appointment, and please contact us if you’re running late. We want this to be a pleasant experience, and be able to provide you with the time that you deserve!

Insurance We Accept
Aetna
Blue cross Blue Shield
Cigna
Emblem HIP
Fidelis
GHI
Horizon BC BS
United Community Plan
United Health care
United Oxford

Out of Pocket Fees
$60 Metabolic Test
$40 In-body test body composition
$85 Metabolic Test & In-Body
$350 Package of 10 In-body test
$400 Package of 10 routine follow-ups
$225 Initial Consultation
$275 Initial Consultation with Tests
$100 Comprehensive Follow Up
$60 Routine follow-up
$180 Senior citizen rate

Payment and Cancellation
Payments are expected at the beginning of each session (cash, checks, quick pay, Venmo) Cancellations made less than 24 hours in advance are subjected to a $50 fee In the event the insurance doesn’t cover the fee of the appointment, the patient will be responsible for covering the session’s fee. Cancellation policy forms will be reviewed and signed by every patient prior to their appointment to avoid any miss understandings. Credit card or check will be kept on file for the cancellation fee.

MEDICAL RELEASE CONSENT FORM

CLIENT REFERRAL FORM

DR LAB REQUEST FORM

NEW PATIENT NUTRITION HEALTH ASSESSMENT FORM

ONLINE PATIENT NUTRITION HEALTH ASSESSMENT FORM

FINANCIAL AGREEMENT FORM

PRODUCTS & RESOURCES

NEW PATIENT INFORMATION FORM

Sandy Zohni MS RD CDE CDN
2518 Ocean Parkway
Brooklyn, New York, 11235
Tel: 718-376-1616
Email: mydietconnection@gmail.com

Name*
First Middle Last
Address*
Address City State Zip
Home Phone*
Birth Date
Date Format: MM slash DD slash YYYY
Age*
Work Phone
Email Address*
CELL PHONE
HEIGHT*
WEIGHT*
SEX*
- Male
- Female
- Other
OCCUPATION*
MARITAL STATUS*
- Married
- Unmarried
INSURANCE DETAILS
POLICY’S HOLDER’S NAME*
POLICY’S HOLDER’S DOB*
Date Format: MM slash DD slash YYYY
PRIMARY INSURANCE COMPANY*
CO PAYMENT
PRIMARY INSURANCE POLICY NUMBER*
SECONDARY INSURANCE POLICY NUMBER
PRIMARY CARE PROVIDER
CANCELATION POLICY:
I UNDERSTAND AND AGREE THAT (REGARDLESS OF MY INSURANCE STATUS) I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE OF MY ACCOUNT FOR ANY PROFESSIONAL SERVICE RENDERED. IN ADDITION, I AM AWARE THAT ANY CANCELLATION MADE LESS THAN 24 HOURS PRIOR TO THE APPOINTMENT TIME WILL RESULT IN $50 OUT OF POCKET FEE. I CERTIFY THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF KNOWLEDGE. I WILL NOTIFY YOU WITH ANY CHANGE IN MY STATUS OR THE ABOVE INFORMATION.
PATIENT SIGNATURE*
Date*
Date Format: MM slash DD slash YYYY

NEW PATIENT INFORMATION FORM

INSURANCE DETAILS

CANCELATION POLICY:

2518 Ocean Parkway Brooklyn, New York, 11235

09:00 -19:00

718-376-1616

2518 Ocean Parkway
Brooklyn, New York, 11235