Booking Form

Appointment Booking

Thank you for taking the time to complete this form. As soon as I receive it, I will make contact to set up a time and date that is appropriate for you.
Today's Date*

MonthDayYear
Name*

First NameLast Name
Current Age*
Phone Number*
Email Address*
Please let me know if you would prefer an:*

In-person appointmentOnline appointment
Please let me know which package you would prefer:

Book a single appointment (R765)Balance: Monthly Nutrition and Health Coaching and support (R900 per month)
Please would you provide a simple explanation as to why you wish to see me:*
Where did you hear about me?*
By submitting this form I acknowledge that I have read and understood the Terms and Conditions:
I hereby provide consent and permission for Adrian Partridge/Urban Health/Our Space to provide nutrition counselling to myself for which I am legally responsible. I understand that Adrian Partridge/Urban Health/Our Space does not provide medical advice, nor will he diagnose medical conditions.

Adrian Partridge/Urban Health/Our Space may provide me with nutritional support and education that relates to already diagnosed nutritionally-related conditions. Nutrition assessments are intended to be a guide for enhancing my nutritional health and supporting my health goals.

I accept that it will be necessary for Adrian Partridge/Urban Health/Our Space to collect personal, health, and lifestyle information. Medical records and personal information and history will be kept strictly confidential, unless I consent to sharing my medical information. I have agreed to have Adrian Partridge/Urban Health/Our Space keep records of our sessions and to file these in a secure and appropriate place.

Further, I understand and accept that internet-associated activities (such as video calls and text-based conversations) are inherently at risk for a breach of personal information. I understand that if I schedule a web-based session that this implies consent and understanding of these risks.

I have agreed - where neccessary and where appropriate for my care - to have Adrian Partridge/Urban Health/Our Space contact other Health Care Professionals to benefit in my care and to share my personal information. This may be accomplished by letter, phone, or email.
Payment Policy

Please note that payment must be made either in full, or your first instalment paid, prior to your first appointment.

Cancellation Policy

Sessions cancelled within 24 hours will be forfeited, and can be re-booked at the standard appointment rate.

As we have no waiting room...

...please ensure that you are on time for your appointments.
I understand that clicking "I Consent" constitutes my digital signature:*

I Consent
Should be Empty:

Appointment Booking

By submitting this form I acknowledge that I have read and understood the Terms and Conditions: