Patient Inquiry Form

After you complete this form, we will be in touch with you. This form must be completed before we contact you. It helps us to triage/assess and prioritise new appointments, so please provide us with sufficient detail about your child's feeding problems. Many thanks.

Your Child

Child First Name *

Child Last Name *

Child Date of Birth *

Please list all current diagnoses *

Reason for inquiry: what is the feeding problem affecting your child? Please provide enough details so we can adequately assess your request. *

What are all the FOODS, meal replacement drinks and/or formulas your child is currently able to use? Please be as specific and complete as possible. *

What are all the LIQUIDS your child is currently able to drink? Please be as specific and complete as possible *

Has your child been screened for Vitamin B6 in previous pathology testing? *

YesNoI don't know

Do you currently have a Nutrition Care Plan with a personalised daily nutrition script that meets all of your child's nutrition requirements (and which has been developed or approved by a paediatric dietitian)? *

YesNo

What is your child's weight and height? Please be as accurate as possible. We need both weight AND height, please. This information is very helpful in triaging your inquiry. *

Please add any files that you think might be helpful for Michael to consider.

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Who is your child's general paediatrician or developmental paediatrician? *

Message or Comment

Funding *

NDIS Self ManagedNDIS Plan ManagedNDIA ManagedHave applied for NDIS fundingPrivate patient

What is your child's NDIS number? *

If you are NDIS PLAN Managed, which Plan Manager do you use?

Parent Contact Details

Parent First Name *

Parent Last Name *

Parent Email Address *

Please verify your mobile number. *

Send code

Submit code

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Suburb *

Postcode *

Fees, Payments & Cancellation Policies

Please CONFIRM you have READ about and AGREE to our fee rates, cancellations, late payments, late arrivals and no-shows. All of this information is available here: www.michaelhann.com.au/appointments *

Terms and Conditions

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Please take the time to read through the appointment and fee information online, including our cancellations policy.

We highly recommend that parents do not skip this step. It just takes a few minutes.

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