Kim Pettifer-Bellamy Pre-Consultation Form

PRACTICE DETAILS
Contact number: 083 408 8904
Email: info@roslynlabuschagnedietitian.co.za

We are equipped for online consultations

CLIENT DETAILS

Email *

Full Name *
First
Last

Phone *

ID Number *

Please choose a payment option

Please Select Your Prefered Payment Agreement (A 3,5% Fee Is Added If Card Facilities Are Used) *
Medical Aid Consultation: ICD Code 84205
Private Consultation: R590
Meal Plan Medical Aid Rate : ICD Code 84205
Meal Plan Private: R600 - unless otherwise quoted
I am unsure, I will decide at the appointment

When claiming from your medical aid we submit on 2 consecutive days. One is for the meal plan and the other is for the consultation.

I understand that 2 claims will be submitted to my medical aid
Yes

Medical Aid Schemes *
Discovery
De Beers
Genesis
Medscheme
Providence/Thebe
Bestmed
Camaf
Keyhealth
Metropolitan
Medihelp
Momentum/Gems
PHA (Private Health Administrators)
Platinum Health
Profmed
Primecure
Resolution Health/Agility Health
Samwumed
Sizwe
Universal
Umvuzo
WCMAS (Witbank Coalfields Medical Aid Society)
BCIMA (Building Contruction Industry Medical Aid Fund)
My Medical Aid Is Not Listed Above

Medscheme - Choose Your Medical Aid
Aeci Medical Aid Society
Barloworld
Bonitas
Bonitas Boncap
Eyethumed
Fedhealth
Horizon
Hosmed
MBmed
Medipos
Medshield
Namibia Health Plan
Nedgroup
Parmed
Polmed
Sabc

Providence - choose your medical aid
Sisonke
Medimed
Suremed
Rhodes University Med
Impala Medical

Metropolitan - Choose Your Medical Aid
Bp South Africa
Fishmed
Golden Arrow Benefit
Moto Healthcare
Pg Group
Pick N Pay Med Scheme
Transmed
Wooltru

Momentum - Choose Your Medical Aid
Health4me Momentum
Impala Medical Plan
Momentum Medical Scheme
Momentum Medicross
Nampak
Botsogo
Imperial Motus Med
Sasolmed
Workaway International
Bp South Africa
Fishmed
Golden Arrow Benefit
Moto Healthcare
Pg Group
Pick N Pay Med Scheme
Transmed
Wooltru

Primecure - Choose Your Medical Aid
Anglo Medical Primecure
Bonitas Primecure
Day 1 Health Primecure
Eyethumed Primecure
Flexicare
Kaelo Health
Lion Health
Momentum Prime Cure
Primecure
Protect Primecure
Randgo Primecure
Sanlam Everyday Healthcare
Suremed Primecure
Sureone Primecure
Thlakano Primecure
Transmed Primecure
Umvuzo Primecure

Please State Your Medical Aid If Not Listed Above

Medical Aid Number (if not applicable type '0') *

Medical Aid Plan (if not applicable type n/a) *

Your Address *
Address Line 1
City
State / Province / Region
Postal Code

Treating Doctor Or Other Health Care Professionals *

Gender *
Male
Female

Your Age *

Weight (in kg) *

Height (in cm) *

Weight Changes *
No weight changes
Gained weight
Lost weight

I Have Had Previous Dietary Meal Plans, Interventions Or Education On Nutrition *
Yes
No

Describe Your Exercise Program *

OUR COMMITMENT AND YOURS

Were You Referred Or Did You Seek Us Out? *

What Do You Want Out Of The Consultation *

If You Are Not Sure How To Answer The Above Question. Here Are Some Suggestions. *
BESTMED Wellness Program
Discovery Vitality Points
DNA Testing
Allergy Testing
OPTIFAST Program (diabetes and weight lost management)
Meal Plan
Education On Nutrition
I Am Still Not Sure

What Stops Or Hinders You From Achieving What You Want? *

If You Are Not Sure How To Answer The Above Question. Here Are Some Suggestions. *
Time Constraints
Finances
Lack of Knowledge
Lack of Motivaiton
I Do Not Have Any Hinderances

WHAT IS THE PROCESS?

FIRST APPOINTMENT:

1. Discuss your answers
2. Set goals and develop your action plan
3. Agree and get started in the follow up

REQUIRED INFORMATION

What Are Your Chronic Conditions (i.e. diabetes, high blood pressure, cholesterol etc) *

List Your Medications And Contraceptives If Applicable (please include doses and times of day) *

Food Allergies Or Intolerances *

Supplementation (vitamins and minerals and sports enhancements) *

PLEASE ADD THE FOLLOWING APPS

Please download the following apps from Google Play Store or Apple App Store:
FatSecret |InBody

BANKING DETAILS TO BE LOADED TO AVOID 3.5% CARD FACILITY FEES

ROSLYN LABUSCHAGNE DIETITIAN
FIRST NATIONAL BANK
ACCOUNT NUMBER: 629 251 35685
BRANCH CODE: 211021
VINCENT PARK
REFERENCE: NAME AND SURNAME
(INVOICE NUMBER IF MULTIPLE PAYMENTS)

ACCOUNT TO BE SETTLED AT THE END OF YOUR CONSULTATION

WE LOOK FORWARD TO MEETING YOU

CANCELLATION POLICY

I understand that 100% cancellation fee will be charged if I do not cancel my appointment 24 hours in advance
Yes

STRICTLY INFANTS (UP TO 5 YEARS)

Please note Kim will only be consulting on Saturday mornings from 9-12

Please complete the form before your initial 60 minute session.

Once you submit this form you will be redirected to Calendly to choose a date and time for your initial 60 minute appointment.

Should the form not submit, please WhatsApp 0834088904 to get access on a different platform!