Client booking form

BOOKING INFORMATION

The following information is used to create your client file.

If you would prefer, you can call us on 1300 971 609 to provide this information.

Child's first name *

Child's last name *

Child's pronouns

Child's date of birth *

Parent/Career's first name *

Parent/Career's last name *

Parent/Career's pronouns

Mobile number *

Email *

Timezone *

Billing Information *

NDIS plan-managedNDIS self-managedNDIA managedPrivateCare Plan from GP

Plan Manager *

Email for invoices *

NDIS Plan Number *

Plan start date *

Plan end date *

NDIS funds allocation

Capacity Building - Improved Health & Wellbeing. Line item: 12_025_0128_3_3 9+ years old: Capacity Building - Improved Daily Living. Line Item: 15_062_0128_3_30-8 years old: Capacity Building - Improved Daily Living. Line Item: 15_062_0118_1_3

Funding to allocate for Dietetics: *

Does your child's NDIS plan have funding periods? *

YesNo

Please provide dates and funds allocated to Dietetics. *

You will be required to setup payment details in Tyro Health (Medipass) and will be sent a text message to complete this step.

We are unable to accept NDIA (National Disability Insurance Agency) managed clients, please contact us on 1300 971 609 to discuss.

A copy of your child's NDIS plan is required prior to booking your initial appointment. Please email a PDF copy to hello@kidsdigfood.com.au

Please ensure a copy of your Care Plan is emailed to hello@kidsdigfood.com.au prior to your 1st appointment.

Medicare Number *

Child Medicare Reference Number *

Parent Medicare Reference Number *

Parent Date of Birth *

Preferred appointment type/s *

Telehealth (phone)Telehealth (video - no program required, opens in web browser)Carseldine clinic, 41 Graham Rd

If you are requesting home visits, please provide your address:

Street addressStreet address line 2

City

State

Postcode

Country

Please briefly explain your nutrition concerns

Where did you hear about Kids Dig Food?

Source Kids ExpoGoogleOther internet search engineFacebookInstagramGPSpeech PathologistOccupational TherapistPsychologistDietitianPaediatricianFriend / familyOther

Name of Health Professional and clinic

Please provide details

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