GAPS CLINIC BOOKINGS

OPEN HOURS: 9AM - 2PM Mon to Friday
LOCATION: Brisbane, Birkdale QLD

All scheduled appoitments take place in person within our clinic. These are conducted over three consecutive appointments. The first two appointments are an essential part of our program, however the follow up can be optional.

*Skype consultations are offered in special circumstances and this can be requested in writing if there are access issues.

Name of person completing the form Name of person completing the form * First Last
Phone Number *
Email *
Skype address (if a video consultation is requested)
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please indicate 3 available blocks of time to which you are available to visit our clinic and we will do our best to accommodate your request. (international consultations times will require special arrangements) *

Please indicate 3 available blocks of time to which you are available to visit our clinic and we will do our best to accommodate your request. (international consultations times will require special arrangements) Monday between 9am - 2pm Tuesday between 9am - 2pm Wednesday between 9am - 2pm Thursday between 9am - 2pm Friday between 9am - 2pm International Appointment
Please indicate whether this is your initial visit to our clinic, your second consultation or a follow up appointment. *

Please indicate whether this is your initial visit to our clinic, your second consultation or a follow up appointment. Initial Consultation - Nutrition Analysis Second Consultation - Intervention Plan Third Consultation - Follow up
Please indicate your consultation preference

Please indicate your consultation preference I/we will attend the appointment at the GAPS Clinic I/we wish to request a skype consultation

Please indicate how many people the consultation package is required for. Each booking includes an assessment with one 'Nutrition Analysis' and one 'Intervention Plan'. If additional assessments are required, please indicate below. Each additional assessment incurs a further $75 fee per person. (if you enter the incorrect option below and can not undo it, you will need to refresh the form and start again)
	ADULT	CHILD	FAMILY
The whole family but only one assessment is required (this fee is included in the consultation cost).	The whole family but only one assessment is required (this fee is included in the consultation cost).ADULT	The whole family but only one assessment is required (this fee is included in the consultation cost).CHILD	The whole family but only one assessment is required (this fee is included in the consultation cost).FAMILY
One person only (this includes a full assessment and the fee is included in the consultation cost).	One person only (this includes a full assessment and the fee is included in the consultation cost).ADULT	One person only (this includes a full assessment and the fee is included in the consultation cost).CHILD	One person only (this includes a full assessment and the fee is included in the consultation cost).FAMILY
2nd Person - additional assessment required - incurs an aditional fee	2nd Person - additional assessment required - incurs an aditional feeADULT	2nd Person - additional assessment required - incurs an aditional feeCHILD	2nd Person - additional assessment required - incurs an aditional feeFAMILY
3rd Person - additional assessment required - incurs additional fee	3rd Person - additional assessment required - incurs additional feeADULT	3rd Person - additional assessment required - incurs additional feeCHILD	3rd Person - additional assessment required - incurs additional feeFAMILY
4th Person - additional assessment required - incurs an additional fee	4th Person - additional assessment required - incurs an additional feeADULT	4th Person - additional assessment required - incurs an additional feeCHILD	4th Person - additional assessment required - incurs an additional feeFAMILY
5th Person - additional fee required - incurs an additional fee	5th Person - additional fee required - incurs an additional feeADULT	5th Person - additional fee required - incurs an additional feeCHILD	5th Person - additional fee required - incurs an additional feeFAMILY
6th Person - additional assessment required, incurs an additional fee	6th Person - additional assessment required, incurs an additional feeADULT	6th Person - additional assessment required, incurs an additional feeCHILD	6th Person - additional assessment required, incurs an additional feeFAMILY

Please indicate whether you have any special access requirements to attend your appointment. Skype appointment requests need to be in writing.
Please confirm that you have read and agree to our Company Consent, Disclosure, Disclaimer of Services Provided & Cancelation/Refund Policy *

Please confirm that you have read and agree to our Company Consent, Disclosure, Disclaimer of Services Provided & Cancelation/Refund Policy I hereby confirm that have read and agree to GAPS Diet Australia's terms and conditions as displayed below. Please scroll to read full content.
Consent, Disclosure and Disclaimer of Services Provided & Cancelation Policy

By visiting the GAPS Diet Australia Pty Ltd Clinic and using our services, including any information provided, the following terms and conditions apply. In using the GAPS Diet Australia Clinic & Services, you agree to be bound by these terms and conditions and hereby release GAPS Diet Australia Pty Ltd and our Clinic services from any liability related to the suggestions or information received.

DISCLAIMER
All advice and information provided at your consultation is based on sources believed to be reliable and accurate at the time of release. It is not to be mistaken for medical advice and we will at all times, refer you to a medical doctor should you seek advice beyond our professional capacity. GAPS Diet Australia Pty Ltd and it’s personnel do not accept legal liability or responsibility for any claimed consequences arising from the advice given by a GAPS Practitioner within our clinic. Our clinic staff each have their own ‘professional indemnity insurance’ and are qualified to carry out the support required within our clinic.

Practitioners within our clinic do not provide medical advice and do not intend to diagnose, prescribe or treat disease, but provide wellness information to aid individuals to reach their quest in reaching an optimal level of health from the benefits of good nutrition. Guests reading information within our website and clients receiving wellness information from Certified GAPS Practitioners within our clinic therefore, acknowledge that the suggestions for use of nutritional supplements, and/or information about nutrition are not intended as a substitute for consultation with a qualified medical practitioner and individuals are encouraged to read the entire label of products purchased for personal use. If you experience any unusual symptoms after following the label directions, you should stop taking the product and call you medical practitioner.

GAPS CLINIC FEES & CHARGES
The Clinic Consultation fees are displayed on our website with additional charges for extra time runing over the allocated appointment scheduled. If consultations run over the allocated booking time, an additional fee for the practitioner’s time will be charged in 15 minute incremental intervals and this will be charged to the client’s credit card at the end of the consultation appointment. The practitioner will of course be mindful of this time and remind the client when this time approaches, however extended consulting time can be offered if the clinic has the available time to stretch the consultation further and the client is happy to continue and acknowledge the additional fees incurred. In accepting an appointment within our clinic, the patient agrees to be charged for the set fee for additional time that runs over the allocated appointment schedule.

GAPS DIET AUSTRALIA CLINIC APPOINTMENT CANCELLATION AND REFUND POLICY
Due to the level of disruption a cancellation can incur to our business procedures and allocated appointment schedule with our practitiooners, a $50.00 Cancellation Fee will apply if the appointment is cancelled in advance (any time up to but not including 10 days prior to the scheduled appointment time). If the cancelation is received after this time with as little as 10 days remaining before the scheduled appointment time, then a refund of only 50% will be granted. This refund is put into place to protect the GAPS Practitioner who begins preparing the patient Nutrition Analysis review or the development of Nutrition Intervention Plans and the reserved clinic room booking loss. If an appointment simply needs to be rescheduled and notice is given in advance of 10 days prior to the appointment time, a cancelation fee will not apply, however all rescheduled appointments will need to take place within a three month period from the date the consultation was purchased and booked.

COPYRIGHT
GAPS Trade Mark
GAPS™ and Gut and Psychology Syndrome™ are the trademark and copyright of Dr. Natasha Campbell-McBride. The right of Dr. Natasha Campbell-McBride to be identified as the author of work contained within the GAPS Australia Website has been asserted by her in accordance with the Copyright, Patent and Designs Act 1988.
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Time - usually 9.30 - 11.30am (2hrs) Time - usually 9.30 - 11.30am (2hrs) : HH MM AM/PM
Time - usually - 9.30 - 11am (1.5hrs) Time - usually - 9.30 - 11am (1.5hrs) : HH MM AM/PM
Time - Either 9.30 - 10.30am (1hour) or 9.30 - 10am Time - Either 9.30 - 10.30am (1hour) or 9.30 - 10am : HH MM AM/PM

GAPS CLINIC BOOKINGS

GAPS CLINIC BOOKINGS

Consent, Disclosure and Disclaimer of Services Provided & Cancelation Policy