Dear _____Pat_________,

This is a reminder of your one-hour consultation appointment with a, Registered

Dietitian, Certified Diabetes Educator, at St. Mary Mercy Hospital. Your appointment is as
follows:
DAY/DATE: ____Friday November 20, 2009
TIME: ____11:00 AM____________________________
LOCATION: St. Mary Mercy Hospital, 36475 Five Mile Rd., Livonia (southwest
corner of Five Mile Rd. and Levan).
PARKING: Parking is available in the south lot from Levan Rd.
ENTRANCE: Use the south entrance from Levan Rd. Use Marian Professional
Building Elevator to the Fourth floor, Suite 412 to the Community
Outreach Dept.
FEE: $120.00 per hour consult. This may be a covered insurance benefit.

IMPORTANT
NOTE: __ The enclosed forms must be completed and returned prior to
your appointment with the dietitian. You may return them by
fax (734) 655-4254, mail them in the enclosed business reply
envelope or deliver them in person.
X Please bring completed forms to appointment.
___ Nutrition History and Assessment Form
___ Medical Release Form

May be needed from your physician:

___ Prescription is required if billing your insurance company.
Also needed:
___ Please bring your insurance card(s), driver license or picture ID, so we can bill your
insurance company for services.

If you are unable to keep this appointment, or you are unable to complete the forms, please call
our secretary as soon as possible for assistance, (734) 655-8955. Thank you.

Sincerely,

Community Outreach Department

DietConsltConfJS(8.08)