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  • Home
  • About Us
    • Who We Are
    • Our Team
  • New Patients
    • Medical Consultations with Dr Hayter
    • Nutrition Consultations with Sonya Cacciotti
    • Advisory Consultations with Dr Hayter
  • Client Information
    • Making an Appointment
    • Scripts and Referrals
    • Obtaining Test Results
    • Reminder System
    • Test Requests
    • Contacting Our Practitioners
    • Telehealth Appointments
    • Payment
    • Cancellation Policy
    • Fee Structure
    • Make an Appointment
  • Webinars
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IV Infusion Questionnaire

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Patient Details

Name*
Please enter your date of birth in the format DD/MM/YYYY
Please enter a number from 0 to 100.
DD slash MM slash YYYY
Please enter the date in the format DD/MM/YYYY
(if not Dr Hayter)

General Questions

What are your current health concerns?
Concerns
How long have you experienced these symptoms
 
Please list each concern individually, press the + key to add a new concern
Have you previously received an IV Vitamin infustion?*

Reason for Seeking IV Therapy

You may tick more than one.*

Medical History

Please tick YES or NO to the following:
Are you currently pregnant or breastfeeding?*
Do you have kidney disease, impaired kidney function or a history of kidney stones?*
Do you have liver disease or abnormal liver function?*
Do you have heart disease (eg. Congestive heart failure, arrhythmias)?*
Do you have high or low blood pressure or suffer dizziness?*
Do you have G6PD deficiency (a red blood cell disorder)?*
Do you have hemochromatosis or other iron storage disorders?*
Do you take any blood thinners (e.g. warfarin, aspirin)?*
Do you currently have a fever or acute infection?*
Have you ever fainted or felt faint during injections or blood draws?*
Do you have any active cancer or are you undergoing chemotherapy/radiation?*
Do you have diabetes or blood sugar regulation issues?*
Do you suffer from migraines or neurological disorders?*
Have you had an allergic reaction to any medications, vitamins or preservatives?*
If you answered yes to allergies, please specify:*
Please list each allergy individually, press the + key to add a new allergy.
Are you currently taking any supplements or medications?*
If you answered yes to taking supplements or medications, please specify:*
Please list each supplements/medications individually, press the + key to add a new item.
Have you had any past medical procedures?*
If you answered yes to past medical procedures, please specify:*
Please list each procedure individually, press the + key to add a new item.

Intravenous therapies are sometimes considered outside the scope of conventional medicine in Australia. However, they are well established treatments within integrative medical practice both here and internationally. These therapies are only prescribed and administered with care and professional oversight.

Please note:

  • These treatments are not funded by Medicare and may not be claimable through private health insurance.
  • In the setting of cancer care, IV therapy may be used as an adjunct (supportive) treatment but it is not a replacement for standard medical care.
  • For safety and comfort, our IV room cannot accommodate support people during your treatment. Friends or family members will be asked to wait in the waiting area.
  • If you are not already a current patient of Dr Hayter, you will need to provide recent pathology results before beginning IV therapy. These must include:
    • G6PD enzyme testing
    • Renal (kidney) function tests
    • Calcium levels (for patients with cancer)
    • Routine blood tests as appropriate

Potential risks and side effects may include:

  • Local irritation or bruising at the IV site.
  • Rarely, vitamin C may impact kidney function through oxalates.
  • In individuals with G6PD deficiency (a rare inherited condition), red blood cells may be damaged or destroyed. For this reason, you may require a blood test before treatment.
Patient Declaration*
Clear Signature

Visit

32 Tamar St
Ballina NSW 2478
Australia

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Contact

Phone: 02 6686 9199

International: +612 6686 9199

Email: info@ballinahealthcentre.com.au

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