LUMEN DIETITIANS
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Diet therapies
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Dietitians
Dr Alice Day
Samantha Plush
Rachel Davis
Tennealle Scinto
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Self referral form
Self-referral form
Please complete the self-referral form to make an appointment with one of our experienced gastrointestinal Dietitians.
Due to our area of expertise and waiting lists, referrals for non-gastrointestinal nutrition problems are not able to be seen in our practice.
Once a self-referral has been received, it will be processed and a member of our administration team will be in touch with an appointment. The current wait times for appointments are up to 8 weeks depending on the gastrointestinal issue. Our team will place you on a wait list and be in touch if an earlier appointment becomes available.
All appointments can either be attended in person, via phone or telehealth. Please let our team know which you would prefer.
*
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Name
*
First
Last
Please complete the following information to refer yourself to see either Alice or Samantha. One of our lovely receptionists will be in touch shortly to make an appointment for you.
Age (years)
*
Date of birth
*
Contact number
*
Email
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
If you do not have a referral from a health professional, please provide your address to assist our reception team in completing your client registration form
Referral reason
*
Please outline the dietary support, information or assistance you are seeking
Self-referral supporting information
*
Crohn's disease
Ulcerative colitis
Irritable bowel syndrome
Troublesome gut symptoms
Food intolerances / allergies
Coealic disease
Liver disease
Pancreatic disease
Eosinophilic oesophagitis
Coloestomy / ileostomy / pouch
Pre-gut surgery
Post-gut surgery
Diverticulitis
Disordered / restrictive eating
Enteral tube feeding
Home parenteral nutrition
Other
Please indicate if you have any of the following health issues:
Preferred clinic location
*
Option 1: Hutt Street, Adelaide
Option 2: Stirling Hospital, Stirling
Option 3: North Eastern Community Hospital
Option 4: Virtual clinic: phone or video consult
Option 5: Any location
Any other information
*
If you have any other information to assist us in making an appointment for you with one of our Lumen Dietitians, please provide details
Submit
About
Diet therapies
>
Research
Dietitians
Dr Alice Day
Samantha Plush
Rachel Davis
Tennealle Scinto
Services
Fees & rebates
Contact
Self referral form