New Patient Enquiry - Ballina Health Ballina Health

New Patient Enquiry Form

Please complete this form if you are interested in becoming a patient at Ballina Health Centre

First Name*
Middle name
Last name*
Preferred name
Date of birth*
Sex*
- Male
- Female
- Other
Type of consultation you are enquiring about?
- Lifestyle medical consultation with Dr Hayter and team
- Nutritional Consultation with Sonya Cacciotti
- Counselling - Jodi Gibbs
- Weber Medical Laser
Please view the services menu for further information and pricing on each of the consultation types we offer
Your primary health condition or reason enquiring about the services at Ballina Health Centre?*
Please comment on previous treatments you have tried to address you health concerns?*
Ballina Health Centre incorporates lifestyle prescription/changes within the scope of our treatment plans, are you prepared to consider making such changes?*
Ballina Health Centre conducts case conferences for all medical patients to support formation of treatment plans involving multiple care options to improve health and life quality. Your health information will be discussed during these meetings with Dr Hayter, our practice nurse and our registered nutritionist. Do you consent to Ballina Health Centre's case conferencing?*
Lifestyle modification often requires regular maintenance consultations to assess progress and adjust your program as needed, are you prepared to invest time into your health by attending ongoing consultations if required?*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
My postal address is...
- the same as my residential address
- different from my residential address
Postal Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone Number
Mobile Phone Number
Work Phone Number
Email
Clinic Policies - Reminder System*
- Our practice is committed to preventative healthcare. We may issue you with a reminder letter from time to time offering you preventative heatlh services appropriate to your care. We do also offer SMS reminders for your booked appointments. If you do not wish to be part of these systems please let us know at reception.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Pathology testing*
- As a lifestyle and prevention based clinic, we order a combination of Medicare-funded and private investigations. Medicare has specific guidelines for GP's to follow when ordering Medicare-funded tests, these must be clinically relevant and written within a consultation. Private testing may be suggested to optimise your treatment program and will incur out of pocket expenses if you choose to proceed. Investigations suggested by external practitioners that are not considered clinically relevant by Medicare or required outside of a medical consultation will need to be ordered privately.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Obtaining Test Results*
- If you have had tests performed and Dr Hayter should consider it necessary to discuss them with you, one of our team members will contact you by phone or email to set up a time to see one of our practitioners. We will only contact you if it is necessary for the Doctor to see you. Your most recent pathology test results can be printed and given to you at the time of your consultation with Dr Hayter (once they have been discussed with you). Please ask our receptionist if you would like a copy of your results, please note that we can’t email, fax or post your results to you or a third party.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Management Of Your Personal Information*
- Your medical record is a confidential document. It is the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.
Please tick box to confirm you have read and understand this policy
Clinic Policies - eHealth Record*
- Your eHealth record provides online access to a summary of your important health information, which you can share with other healthcare professionals involved in your care. The eHealth record is a handy and convenient means of keeping track of all medications, immunisations or treatments you receive. This will be discussed with you at the time of your consultation. Please let one of our team members know if you do not wish to have an eHealth record or require further information.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Cancellations*
- We request that cancellation of 1st and all long appointments be made at least 5 business days prior to the consultation date and at least 24 business hours before the consultation date for all other appointment types. This will enable us to allocate your appointment to a waiting client. Failure to cancel you appointment may attract a fee equal to 50% of the consultation fee.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Contacting Our Practitioners*
- Our practitioners may be contacted by phone during normal opening hours. If unavailable at the time, our receptionist will take a message and advise when your call is expected to be returned. It may not always be possible for Dr Hayter to return your call but if a message is left with one of our team members Dr Hayter can advise them and they will return your call on his behalf. Please let the receptionist know if your call is an emergency. You may also email the practice at any time. Please note that emails are not always a confidential means of communicating and may attract a fee.
Please tick box to confirm you have read and understand this policy
Clinic Policies - Payment*
- Payment: Please refer to the schedule of fees for details on different services and treatments. No accounts are offered. Payment is due strictly at the time of consultation. Facilities for cash, credit cards and EFTPOS are available. Cheques are not accepted. Telephone, Skype and Email consultations are to be paid at the time of consultation via credit card. Please note that these consultations do not attract a Medicare rebate. Supplements must be paid for in full prior to dispatch and cannot be returned or exchanged. No accounts are offered.
Please tick box to confirm you have read and understand this policy
How did you hear about the Ballina Health Centre?*
Please be specific, if you were referred by a relative, friend or practitioner include their full name
Please leave any additional comments or questions here - optional

phone (02) 6686 9199 | 32 tamar street, ballina