Dietitian Consultation Booking & Agreement

Dietitian Consultation Booking & Agreement

Please fill out the form accurately to book your appointment with registered dietitian, Nikki. By submitting, you agree to our cancellation policy and legal terms.
Full Name of Client*

First NameLast Name
Email Address*
example@example.com
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Reason for seeing Dietitian
How did you hear about this practice?
EnglishAfrikaans
Medical Aid Provider Name (if applicable)
Medical Aid Membership Number (if applicable)
Medical Aid Main Member (if applicable)
Your ID Number*
Main Member's ID Number
Nouriq – Client Agreement
This agreement is designed to ensure clarity and transparency regarding consultations, billing, and cancellation policies. Please read carefully before booking.

1. Payment terms
- Claims will be submitted directly to the client’s medical aid where applicable.
- Private-paying clients are required to settle payment immediately after the consultation/session, unless otherwise agreed in writing.
- Where payment has been pre-arranged, invoices are payable via EFT within 14 days of receipt, unless otherwise agreed in writing.
- Please note that card facilities are not permanently available on-site, and card payments outside of the consultation time require prior arrangement.
2. Cancellation policy
- Appointments must be cancelled or rescheduled at least 24 hours in advance.
- Cancellations made with less than 24 hours’ notice, or missed appointments, will be billed in full.
3. Fees
- Fees are based on the current Board of Healthcare Funders (BHF) rates.
- Consultation times are approximate (e.g. initial ~60 minutes, follow-up ~30 minutes) and may vary according to your needs.
4. Legal terms
- The terms of this agreement are binding. Should it become necessary to institute legal proceedings for non-payment, you will be responsible for all legal costs, including attorney fees, tracing costs, and collection commission.
- By signing this agreement, you acknowledge that you understand and accept these terms.
5. Communications of Concerns
- If you are dissatisfied with the service received, please raise your concern within 14 days of the consultation so that it can be addressed promptly.
Service Details and Rates
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Initial Consultation + Meal Plan (60 minutes)
A comprehensive session where we’ll review your medical history, lifestyle, current symptoms, weight journey and goals. We’ll also complete a InBody assessment (in-person consult) and explore your dietary habits and preferences. Together, we’ll set clear goals and create a personalized action plan. This includes a customized meal plan tailored to your specific needs. Virtual consults are R910

1,030.00ZAR



Couple Initial Consultation (90min)
A comprehensive session where we’ll review both your medical history, lifestyle, current symptoms, weight journey and goals. We’ll also complete InBody assessments and explore dietary habits and preferences. Together, we’ll set clear goals and create a personalized action plan. This includes customized meal plans.

1,480.00ZAR



Medscheme Weight Management Program (2x Consultations)
This option is for Medscheme* clients referred by their biokineticist and includes both an initial and a follow-up consultation with the dietitian. Claims are submitted directly to your medical aid, so there’s no out-of-pocket cost for eligible members. *[Polmed, SAMWUMED, Fedhealth, Bonitas]

FreeZAR



Vitality Nutrition Assessment (30 - 40 min)
To review your eating habits, body composition and health goals. You’ll receive personalized guidance to support better nutrition and earn 1 000 Vitality points. No meal plan included. Please note: Medical aid reimbursement is dependent on your individual plan and available benefits. Clients are responsible for any outstanding balance.

534.00ZAR



Follow-up Session (30-40 minutes)
A focused check-in to review your progress, address challenges and fine-tune your plan. We’ll assess how your goals are tracking, repeat an InBody assessment and make any necessary adjustments to your meal plan or strategies and provide practical guidance to keep you moving forward with confidence. Virtual follow-ups are R400

550.00ZAR



InBody Assessment Only
An InBody 120 assessment uses bioelectrical impedance to measure what your body is made of (muscle mass, body fat, visceral fat, hydration), giving a fast, science-based picture of your progress beyond the scale.

240.00ZAR
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Client Signature for Agreement*

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