Medical Nutrition Therapy Referral Intake Form

Medical Nutrition Therapy Referral Intake Form

Medical nutrition therapy (MNT) is a vital component of comprehensive patient care, particularly for individuals managing chronic conditions like diabetes, cardiovascular disease, kidney disease, and gastrointestinal disorders. Our Medical Nutrition Therapy Referral Intake Form streamlines the patient onboarding process for registered dietitians, nutrition clinics, and healthcare facilities offering dietary intervention services.

This template is specifically designed for healthcare providers, dietitians, nutritionists, and wellness centers who need to gather detailed patient information before the first consultation. It captures everything from medical diagnosis and current medications to eating patterns, cultural food preferences, and insurance pre-authorization requirements—all in one professional, HIPAA-compliant collection point.

Why this form works for nutrition therapy practices

Instead of juggling paper forms, phone calls, and scattered email threads, this intake form creates a clear, consistent onboarding experience that helps your team prepare for each patient encounter. You'll collect the medical context you need to build personalized nutrition care plans while respecting cultural traditions and insurance protocols.

The form includes conditional logic to reveal relevant follow-up questions based on diagnosis and dietary restrictions, helping you gather complete information without overwhelming patients with irrelevant fields.

Streamline your practice with Paperform + Stepper

Once a patient submits this intake form, you can use Stepper to automate your entire nutrition therapy workflow:

• Automatically create patient records in your practice management software or CRM
• Send insurance pre-authorization documentation to billing staff
• Trigger appointment confirmation emails with preparation instructions
• Route urgent cases or complex diagnoses to senior dietitians for review
• Update your scheduling system and send calendar invitations

This automation means your front desk and clinical teams spend less time on data entry and more time providing personalized nutrition care.

Secure, professional, and ready to customize

Built on Paperform's SOC 2 Type II compliant platform, this template meets the security standards healthcare practices require. You can easily customize the form to match your clinic's branding, add your logo, modify questions to reflect your specific protocols, and connect it to the tools you already use—whether that's Google Sheets, your EHR system, or a patient portal.

Whether you're a private practice dietitian, hospital-based nutrition department, or integrated wellness center, this Medical Nutrition Therapy Referral Intake Form gives you a professional, efficient way to welcome new patients and start them on the path to better health through evidence-based nutrition care.