Client Information Client Information Sex:MF Chose clinic because/referred to clinic by - Please select an option and then include specifics in the area below. Please selectDoctor/PhysioFamily/FriendArticle/PresentationOther Additional Information If Client is not paying this account, who is responsible? Is this a Medicare “Care Plan”? YesNo Incase of Emergency The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance. I also authorize nutrition works or insurance company to release any information required to process my claims.