CAROLINA NUTRITION (Adult & Pediatric)
Anju Agarwal, MS, RD/LDN, CNSD, CDE
Please Fax Referral to (704) 655-ANJU (2658) or call (704) 890-3162
1918 Randolph Road, Suite 440, Charlotte, NC 28207
17538 Invermere Ave, Huntersville, NC 28078 (Office & Mailing Address)
E-mail:
www.carolinanutrition.com
Patient Name ______DOB______MR# ______
Patient Phone (Home/ Work) ______Cell Phone ______
Patient Address ______
Physician Name______Facility ______
Physician Phone______Physician Fax______
Physician Address______
Please specify nutrition services to be provide:
Diet Order: ______
Pertinent Labs (pertinent to nutrition therapy):
Please include recent medical records, laboratory data pertinent to nutrition therapy
Pertinent Dx______Dx Code______
MD/ Clinician______Date______
Evening and Weekend Appointments Are Available
**Will fax copy of the nutrition assessment and recommendations to physician
** Please include a copy of the patient’s insurance card
Patients can be in various locations throughout the Charlotte and Lake Norman Areas. Home visits can be made with extra charge. CAROLINA NUTRITION is a preference for BCBS, ATENA, UNITED HEALTH CARE AND MANY OTHERS INSURANCE CO. Standard charges without insurance coverage are $65.00 for initial consult and $40.00 for follow up and Medicaid/ Medicare patients.