Dietitian appointment request form template
This six-step dietitian appointment form asks the client’s diet goal, how healthy their diet is, how often they cook, any dietary restrictions and notes, followed by the contact details. Clone it into your Growform account and add your appointment types.
What the form asks, step by step
These answers give a dietitian a first picture of the client’s habits before the appointment. The restrictions step allows several answers.
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Step 1: “What’s your main diet goal?”
Weight loss, healthy eating, sports nutrition or plant-based sets the focus.
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Step 2: “How would you rate your current diet?”
A self-rating shows how much change the client expects to make.
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Step 3: “How often do you cook at home?”
Clients who rarely cook need simpler meal plans and shopping advice.
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Step 4: “Do you have any dietary restrictions?”
Gluten-free, lactose-free, vegetarian and vegan can be selected together.
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Step 5: More information
Clients can note medical conditions or medications for the dietitian.
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Step 6: “How shall we contact you?”
Name, email and phone come last.
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After submitting
A practice would edit the thank-you text to say how appointments are confirmed and whether insurance is accepted.
Who it’s for
Registered dietitians, nutrition clinics and online nutrition coaches can use this template to take appointment requests. It works as a short dietitian intake form that covers goals, habits and restrictions, so the first session can focus on the plan. A full nutrition intake form with medical history can be sent once the appointment is confirmed.
Why this structure converts
- Every question is about everyday eating, so clients can answer without preparing anything.
- The self-rating question is gentle, which suits people who feel self-conscious about their diet.
- The restrictions step is multi-select, reflecting that many clients avoid more than one food group.
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Make it yours
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Ask about referrals
Add a question asking whether a doctor referred the client, which matters for insurance and for reports back to the physician.
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Offer online sessions
Add a step asking whether the client prefers a video call or an in-person appointment.
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Keep medical data separate
Use the notes box for brief context only, and collect detailed health history in your practice system.
Send every lead where your team works
Frequently asked questions
What is the difference between this and a nutrition intake form?
This form requests an appointment and gathers the basics. A nutrition intake form collects medical history, medications and a food log, usually before the first session.
Can I send appointment requests to my scheduling tool?
Yes. Growform connects to vcita, HubSpot and Google Sheets, and can redirect clients to your booking page.
Does it work on phones?
Yes. Each question appears on its own screen with large buttons, which suits clients booking from a phone.
What happens next?
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Step 1: Clone this form template
Clone this template into your Growform account (create one first if you don’t already have one). -
Step 2: Edit your form
Get creative and adjust your form's theme options, questions or layout in the Growform form builder. -
Step 3: Share or embed your form
Share a link to your form, or embed it in your existing website. Receive new submissions by email or send them to 7,000+ apps via Zapier.
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