iCare Referral Form - The Healthy Eating Clinic

What iCare Services do you require *

In-clinic consultation

In-home consultation

Video consultation

iCare Participant Name *

iCare Participant Birth Date *

iCare Participant Gender *

Male

Female

Other

iCare Participant Address *

iCare Participant's Phone No. *

iCare Participant's Home Phone No.

iCare Participant's Email *

Alternative Contact's Name

Alternative Contact's Mobile No

Alternative Contact's Email

Relationship with iCare Participant

Alternative Contact's Address (if different from above)

iCare Participant No *

Service Approval No

iCare Service Approval Start Date

iCare Service Approval Expiry Date

Who manages the iCare Funding

Lifetime Care

Other (Specify Below)

Organisation Funding Name *

Organisation Funding Address *

Email Invoices To *

Who manages the iCare Funding (this person will receive appointment confirmation emails and reminders)

Client

Case Worker / Carer (please specify)

Booking Coordinator Name *

Booking Coordinator Email *

Booking Coordinator Mobile No. *

Please provide some information about why this participant is booking with a dietitian *

How did you hear about The Healthy Eating Clinic *

HerCanberra

Facebook

Instagram

Google

The Hub Membership

Shopfront

Word of Mouth

The Daily Dollop Podcast

Health Professional (please specify)

Gym (please specify)

Other (please specify)

Please specify:

I understand *

Please fill out the form below in order to use iCare funding with our clinic. A team member will be in touch with you within 1 business day.

iCare Participant Details (who the nutrition advice is for):

Please complete if you are filling out this form on behalf of an iCare Participant

iCare Service Approval Details

iCare Invoicing Details

Appointment Bookings

How Can We Support You?