New Patient Enquiry - Ballina Health Ballina Health

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
Telehealth Nutritional Consultation with Sonya Cacciotti
Counselling with Jodi Gibbs

Please view the services menu for further information and pricing on each of the consultation types we offer

How would you like to attend?

In person at the clinic
Telehealth via Zoom

Your primary health condition or reason for enquiring about the services at Ballina Health Centre*

Please comment on previous treatments you have tried to address your 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*

If entering a landline, please include the area code

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. Telehealth consultations are to be paid at the time of consultation via credit card, accounts not finalised on the day will incur a late fee of $5 per day. Medicare rebates may apply to some appointments. Supplements must be paid for in full prior to dispatch and cannot be returned or exchanged. No accounts are offered.
Cancellations: If you cancel or reschedule within 10 days of your new patient appointment, a cancellation fee will be charged.

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

New Patient Enquiry Form