Telehealth & In-Office Appointments Available
704-846-7105704-246-6808

Appointment

Confirmation & Appointment Policy

Please read the policies below carefully, then complete the form to confirm your appointment.

Cancellation & Missed Appointment Policy

At MDD, Inc. our Registered Dietitians are by appointment only. A last-minute cancellation or no-show is time another client could have used.

If you must cancel or reschedule, please do so at least 24 hours prior to your appointment time. Call 704-846-7105 to avoid a missed appointment charge. Do not email to cancel.

To schedule an appointment, we require a valid credit card or otherwise acceptable payment method to be kept on file.

Missed Appointment Charge

$75.00

Thank you for respecting this business policy.

Insurance Disclosure Policy

Due to Health Care Reform, it is uncertain if insurance will pay for your visits with the Registered Dietitian. Please note: as per your insurance plan, the quoting of benefits is not a guarantee of payment and the client is responsible if the claim is denied.

Authorization

I hereby authorize My Diabetes Dietitian Inc. to keep my account information on file for payment and to initiate debit or charge entries on this account as amounts are owed to My Diabetes Dietitian Inc. by me.

I acknowledge that the origination of ACH or credit card transactions to my account must comply with the provisions of U.S. law. I understand that a debit or charge may be made to my bank account or credit card account periodically to pay for amounts owed.

If my bank account or credit card information changes for any reason, I will notify My Diabetes Dietitian Inc. This authorization shall remain in effect for two (2) years from the originating date or until My Diabetes Dietitian Inc. has received written notification from me of its termination. In the event of returned ACH or a declined charge, my account may be charged a service fee for each occurrence.

Payment is due in full at time of service.

Self-Pay / Time-of-Service Rates

Initial Appointment$150
Meal Plan Appointment$115
30-Minute Follow-Up$75

Confirm Your Appointment

By submitting this form, you are giving your authorization and indicating you understand and will abide by the Cancellation & Missed Appointment Policy as stated above.

Questions? Call our office at 704-846-7105.