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Welcome to the Practice/ Intake Forms

Dear Client,

You’ve made an appointment to see me and I look forward to working with you.

Prior to your appointment (at least several days before your appointment) I would like you to provide specific information so I can best address your health concerns.

Complete and email to me.

1. Nutrition Intake Form – Select either the Fillable PDF or Printable PDF.

2. Chronological List Health Problems
If applicable, on a separate sheet of paper, please put together a chronological account of health problems, things that were ruled out, any treatments, and how you responded. This should include medications, supplements, diet and any other treatment modalities.

3. Eating Diary   Select either the Fillable PDF or  Printable PDF.
Keep track for 4-7 days.

4. Laboratory Test Results
I would like a copy of your most recent labs, plus any earlier labs or special tests if you feel they are pertinent.

5. Nutrition Supplements
Please have your supplement bottles on hand to reference during the appointment.

6. Credit Card Authorization Form  Fillable PDF or   Printable PDF
If you prefer to have your credit card on file for billing purposes please complete.

I look forward to getting the materials soon and working with you.

Janet Zarowitz, MS, RD, CDN
Integrative and Functional Nutritionist

Note: During the Coronavirus pandemic I am seeing patients via Video Chat or Telephone.
A few minutes before your appointment time click on this link to my virtual waiting room

Counseling Office Address

Janet Zarowitz, MS, RD, CDN
141 North State Road
Briarcliff Manor, NY 10510

Phone: 914-222-3919

Office is in shared suite with Liza Margulies, LCSW.
Enter building under the Red awning.
Take elevator or stairs up one flight.
Parking and entrance are in rear of building, off of Old Saw Mill River Road (not off North State Road).
See map below.

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Cancellation Policy

I understand that things do come up and you may have to cancel an appointment.

As a courtesy to my practice I request that you notify me via email at least 24 hours before your appointment if your need to reschedule.

–Janet Zarowitz, MS, RD, CDN

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