Telehealth Consent Form - Ballina Health Ballina Health

Please complete this form 48 hours prior to your telehealth appointment

First name*
Last name*
Telehealth Consent*
- I agree to participate in a telehealth clinical consultation with my general practitioner, Dr Michael Hayter and/or clinical nutritionist.
- I understand and agree that participation in a telehealth clinical consultation is voluntary.
- I understand and agree that my rights to confidentiality and privacy will be respected
- I understand and agree that delays may occur due to any failures of the electronic equipment
- I understand and agree that the audio/video technology used will meet recommended standards to protect your privacy and security.
- I understand that if I cancel or reschedule my appointment within 48 hours of the appointment, a cancellation fee will be charged. A full appointment fee will be charged for same day cancellations or non-attendance.
Payment*
- I understand that the consultation fee is due at the time of the appointment and that payment details are to be give by phone prior to the appointment (a processing fee is charged if payment information is not received before your telehealth appointment))
Please phone prior to your appointment day to provide your payment details if you have not already done so.
To help us prepare for your appointment, if you require any prescriptions or referrals, please list below. (Please note that all scripts will sent via eScripts and all pathology, referrals and other documentation will be sent electronically)