Participant First Name? *

Participant Last Name? *

NDIS Participant Type *

Agency Managed
Self-Managed
Plan Managed
Nominated Support Contact

I... *

am preparing for my planning meeting
have budget for meal delivery in my plan
currently have meal delivery and am getting ready for my review

NDIS Number *

Date of Birth

Participant Email Address? *

Phone Number? *

Delivery Post Code *

How Many Months Quote to Cover? *

Delivery Address *

Required to send quote to NDIS for approval

How many meals per week? *

7 (1 meal per day)
14 (2 meals per day)
21 (3 meals per day)

Preferred Meals *

Beef Steak & Cheesy Cauli Mash
Thai Green Chicken Curry & Cauli Rice
Creamy Baked Keto Mac and Cheese
Chicken Alfredo & Broccoli Pasta
Chicken Curry Masala & Cauli Rice
Keto Beef Stroganoff & Cauli Rice

Do you have any known food allergies or sensitivities? If yes, please specify *

Are you allergic to any specific ingredients commonly found in keto meals? If yes, please specify: *

Milk
Crustacean
Egg
Fish
Gluten
Peanut
Sesame
Soy
Sulphites
Tree Nuts
Other

Ingredient details *

Have you ever experienced a severe allergic reaction (anaphylaxis) to any food? *

If yes, please provide details

Do you have any medical conditions that may require specific dietary considerations? If yes, please specify *

Are you currently breastfeeding? *

If yes, please consult with your healthcare provider to ensure the suitability of the frozen keto meals for both you and your baby.

Do you have difficulty chewing or swallowing? *

Do you require any modifications to the texture or consistency of the meals to reduce the risk of choking? *

I Agree

Please note that the information provided in this questionnaire will be used solely for the purpose of assessing and addressing potential risks associated with your dietary needs. Your privacy and confidentiality will be respected, and the information will only be shared with relevant parties involved in the meal preparation and delivery process. By submitting this questionnaire, you acknowledge that the accuracy and completeness of the information provided are your responsibility. It is recommended to consult with your healthcare provider or NDIS coordinator to ensure the suitability of frozen keto meals for your specific dietary needs. Thank you for taking the time to complete this risk assessment questionnaire. If you have any further questions or require additional assistance, please feel free to contact us.

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

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