Weight Loss Nutrition Counseling Forms

In order to receive the most out of your appointment, please fill out and submit the forms (below) prior to your appointment. The forms are designed to be transmitted by e-mail. The latest version of Adobe Acrobat Reader is required to complete the forms. If you do not have Adobe Reader X, please download it for free at http://get.adobe.com/reader/. Please note: if you choose not to download this version of Acrobat Reader you will not be able to save the form.

Instructions to save and submit completed forms:

  • Please open each PDF file and fill out as completely as possible

  • When finished, select the 'submit form' button at the top right

  • If you have an Outlook email address, select the first option and click "OK". You will be prompted to send an email with the forms attached using your Outlook software.

  • If you use a web-based e-mail (e.g. Yahoo, Gmail, Hotmail, AOL, etc) select the second option. You will be prompted to save the form to your desktop. After saving to the desktop, compose a new e-mail message and attach the saved documents from the desktop to your e-mail.

  • Please send forms to nutritionclinic@kumc.edu

Forms for New Clients

Returning Client

Helpful Tools

  • Weekly Food and Activity Diary PDF document (icon)

Notice of Privacy Practices

This notice PDF document describes how medical information about patients may be used and disclosed, and how patients can access this information.


Home Service Packages For Clients About the Clinic Location

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KU HealthPartners, Inc. and its clinics are committed to equal opportunity and nondiscrimination in all programs and services, and do not discriminate on the basis of race, color, ethnicity, religion or creed, sex, including marital status, national origin or ancestry, age, sexual orientation, disability, veteran status, gender expression and gender identity. The following person has been designated to handle inquiries regarding the non-discrimination policies: Director of the Office of Institutional Opportunity and Access,IOA@ku.edu, 1246 W. Campus Road, Room 153A, Lawrence, KS, 66045, (785) 864-6414, 711 TTY. http://ioa.ku.edu

Reasonable accommodations are available upon request.

KU HealthPartners, Inc.
Mail Stop 4303
3901 Rainbow Boulevard
Kansas City, KS 66160

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Nutrition Clinic at KU Medical Center
3901 Rainbow Blvd.
Kansas City, KS 66160