Please complete these forms prior to your first session.  Forms may be completed electronically and emailed to gina@eatwellwithgina.com or printed and completed.

New Client Information
(If completing electronically please click to create a “checkmark” to the left of the word when the form specifies to “circle” a response).

HIPPA Agreement

Release of Information

Self-Pay: Payment Policy

Insurance Coverage: Insurance Payment & Financial Policy

Appointments are scheduled for a specific time.  You will be charged 100% for missed appointments unless we are notified of cancellation at least 24 hours in advance, or in cases of emergency.

Physician Appointment Referral Form

About Gina
Gina Consalvo-Hassick, MA, RD, LDN, CDE, NCC is a registered dietitian and is actively involved in various food and nutrition communities. She has counseled and assessed a wide range of patients and has experience in outpatient, inpatient, and consulting. Areas of specialization include weight management, eating disorders, and wellness nutrition.
Follow Gina
Contact

Gina Hassick,
MA, RD, LDN, CDE, NCC

(908) 827-1482
gina@eatwellwithgina.com

Office Location:
133 N. 4th Street
Easton, PA 18042