Appointment Forms

Eileen F Pierro MED, RDN, LD

Welcome to Nutrition Counseling!

Currently I am only accepting self pay patients.  Appointments are 50 minutes in length.  Payment is due at time of visit or before visit.

For appointment scheduling please call 603-247-2998.  Prior to your virtual or in person appointment, email completed forms to or bring forms to appointment.

  1. A copy of laboratory results from your doctor’s office
  2. Personal and Lifestyle History Form
  3. Medication and Supplement List-2
  4. Patient Personal Information Form-2
  5. 3 Day Food Record-3
  6. Acknowledgment of financial responsibility
  7. Authorization for release of confidential information form
  8. HIPPA Guidelines Form