Patient Name *

First Name

Last Name

Parent/Guardian Name (if applicable)

First Name

Last Name

Phone *

(###)

###

####

Preferred Contact Method

Phone

Email

Text

Have a specific RD you'd prefer to see? Check all that Apply. (optional)

Blair Mize (Tennessee + Virtual)

Katie Antonopulos (Tennessee + Virtual)

Rachel Burana (Tennessee + Virtual)

Lauren Dia (Tennessee + Virtual) - Not Currently Accepting New Clients

Carol Ann Dietz (Tennessee + Virtual)

Julia Noel (Tennessee + Virtual)

Monica Porter (Tennessee + Virtual)

Do you prefer in-person or virtual appointments? *

In-Person: Memphis, Tennessee

Virtual: Tennessee

Virtual: Other State (Please note below.)

No Preference

Which insurance do you have? *

Aetna

Aetna Medicare

Cigna

MedBen

UMR

UnitedHealthcare

UHC Community Plan / Medicaid

UHC Medicare

Other