Patient Inquiry Form

After you complete this form, one of our team members 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, drinks and formulas your child is currently able to use? Please be specific and complete as possible. *

Message or Comment

Have you listened to Michael's podcast: All About ARFID? *

YesNo

The podcast can be accessed here: https://allaboutarfid.supercast.com/

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 *

Parent Mobile Number *

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.paediatricdietitian.clinic/appointments *

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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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For security please complete the check below *