Initial Dietitian Information

Dietitian appointment information
Please complete this form before your initial consultation with Sam (Samantha) Fung, our JMC-based dietitian. This information helps Sam tailor your initial appointment to your needs.

There is a cost to appointments with Sam; if you are usure of these then please see Johnsonville Medical - Nutrition.
Email Sender
Full Name
Required
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit year
Best Contact Number
Required
Email address
example@example.com
Do you have any formally diagnosed food allergies or intolerances? If so, what are they?
Required
Are there any foods or beverages that you think you may be intolerant to or have some form of allergy to? If so, what are they?
Required
Are there any foods or beverages that you cannot eat due to cultural, ethical or personal reasons?
Required
Are you taking any supplements at the moment? Please specify.
Required
Have you worked with a nutritionist or dietitian before? If so, please provide as much detail as you feel comfortable to share.
Required
What is your nutrition related goal, or what do you hope to get out of working with Monica?
Required
Some health insurance policies cover seeing a Registered Dietitian in New Zealand. If you have health insurance you may be able to claim back some or all of the costs of working with Sam.
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Dietitian appointment information