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*
Last 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 with 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?*
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?*
Best contact number*
Email*
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