Dietetic Appointment Request Form

Dietetic Appointment Request Form

Let us know how we can help you!
IMPORTANT NOTICE: our dietitian, Krystal, works part time and may not be able to accept all urgent referrals. Please seek urgent medical attention through your GP or Hospital Emergency Department if there has been no oral intake of food or fluids in 24 hours, no oral intake offood (fluid only) in 72 hours or you are concerned for the client's health or safety.
Full Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (+61) 000-000-000.
Email Address
example: admin@r8hfc.com.au
Please privide a brief reason for the dietitian services you are seeking
Date of Birth

DayMonthYear
Date
Address

Street Address

Street Address Line 2

SuburbState / Province

Postal / Zip Code
Appointments are 60 minutes, either in clinic or by teletherapy. Our Dietitian, Krystal, is only available on Thursdays between 9:15am and 11:45am, with limited Saturday mornings. If these times do not work for you or you would prefer a telephone call to schedulethe appointment, please advise.
Urgency of referral
Please be aware our dietitian, Krystal, works part time and may not be able to accept all urgent referrals. Please seek urgent medical attention through your GP or Hospital EmergencyDepartment if there has been no oral intake of food or fl uids in 24 hours, no oral intake offood (fl uid only) in 72 hours or you are concerned for the client's health or safety.
Which professional has referred you for a dietitic consult?
Provide information below
What date and time work best for you?
The date and time selected above will be confirmed by one of our staff members once a confirmation email has been sent to you. Please click 'yes' if you understand.
Please select which one applies to you.
Please note: there is a non-refundable deposit required to secure your appointment. This deposit will be deducted from your total consultation fee following the delivery of your dietetic service.

An email will be sent over to you shortly.
Please reply 'yes' to the reminder email to confirm your attendance.
Should be Empty:

Dietetic Appointment Request Form

Please reply 'yes' to the reminder email to confirm your attendance.