.. Glow Group Health & Wellbeing

Glow Group Health and Wellbeing Consent Form

Dietetic Service

As part of providing a Dietetic service to you, Glow Group Health and Wellbeing needs to collect and record personal information from you that is relevant to your situation, such as your name, contact information, medical history and other relevant information as part of providing Dietetic services to you. This collection of personal information will be a necessary part of the nutrition assessment and treatment that is conducted.

Purpose of collecting and holding information

Your personal information is gathered as part of your assessment and treatment, is kept securely and, in the interests of your privacy, used only by your Dietitian and the authorised personnel of the practice (as necessary). Your personal information is retained in order to document what happens during sessions, and enables the Dietitian to provide a relevant and informed clinical service to you. A more detailed description is provided in the practice’s “Privacy Policy” which can be obtained by contacting Director Jessica Tilbrook. The Privacy Policy contains information about how to access and seek correction of your personal information, and how to lodge a complaint about our management of your personal information.

Disclosure of personal information

All personal information gathered by the Dietitian during the provision of the nutrition consult will remain confidential except when:

  1. it is subpoenaed by a court; or
  2. failure to disclose the information would in the reasonable belief of the Dietitian place you or another person at serious risk to life, health or safety; or  
  3. your prior approval has been obtained to
    1. provide a written report to another professional or agency. e.g., a GP or a lawyer; or
    2. discuss the material with another person, eg. a parent, employer or health provider; or 
    3. disclose the information in another way; or 
  4. you would reasonably expect your personal information to be disclosed to another professional or agency (e.g. your GP) and disclosure of your personal information to that third party is for a purpose which is directly related to the primary purpose for which your personal information was collected; or
  5. You have been referred under the Medicare Chronic Disease Management or Medicare Eating Disorder Plan scheme, where treatment reports are required to be sent by your Dietitian to the referring Doctor; or
  6. disclosure is otherwise required or authorised by law. 

Your personal information is not disclosed to overseas recipients, unless you consent or such disclosure is otherwise required by law. Your personal information will not be used, sold, rented or disclosed for any other purpose.


Session LengthPrice
1-hour session$182.74
45 minutes session$140.00

Fees are paid after your consultation session and are non-refundable.


Medicare - Rebates for Dietitian services are available through Medicare for clients under a Chronic Disease Management Plan (previously known as Enhanced Primary Care or EPC) or a Medicare Eating Disorder Plan. To qualify for these rebates, a referral is required from your GP. Glow Group Health and Wellbeing does not bulk bill, so we do ask that clients kindly pay the difference between the fee charged and the Medicare rebate.

Private Health - Most private health funds offer coverage for Dietitian/Nutrition services as a component of their extras cover. If you are unsure of your coverage we recommend contacting your health fund to see whether you are eligible. Should you have any questions or queries regarding the claiming process the Glow Group team is very happy to help.

Cancellation Policy

For us to provide you with the best and most accessible service, there are fees for cancellations and missed appointments. In order to avoid these fees, please provide us with as much notice as possible.

Cancellations made within 24-48 hours (notice period excludes weekends & public holidays)

50% of usual Session Fee applies

Cancellations made with less than 24 hours’ notice (notice period excludes weekends & public holidays)

Full Session Fee applies

Missed Appointments

Full Session Fee applies

Cancellation fees are charged as this time has been set aside for you and cannot be filled at short notice. These fees are not covered by Medicare; they are your responsibility, and become due immediately.

Glow Group Health and Wellbeing reserves the right to reschedule appointments at any time, without compensation, if it is deemed necessary due to staff illness or other unforeseen circumstance.

Consistent therapy is beneficial for progress, therefore, if more than 2 consecutive cancellations or non-attendance occur, further scheduling of appointments will need to be reviewed.


Your treating Dietitian will not be able to attend to your calls after hours, and outside of sessions. In the event of a crisis please reach out to your GP, or after hours GP. In the event of an emergency please dial 000 or present at your nearest hospital.

Further Services and Programmes




I,    have read and understood this Consent Form. I agree to the above conditions for the Dietetic Consult provided by a Glow Group Health and Wellbeing Dietitian.

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Document name: Glow Group Health and Wellbeing Consent Form
lock iconUnique Document ID: 79cf2e42957813d47a2bfd4ec1db3cbd85af9a32
May 29, 2019 11:21 am AESTGlow Group Health and Wellbeing Consent Form Uploaded by Jessica Tilbrook - hello@glowgroup.co IP
September 25, 2020 4:17 pm AEST Document owner hello@nyssasutherland.com has handed over this document to hello@glowgroup.co 2020-09-25 16:17:11 -