Weber Laser Questionnaire - Ballina Health Ballina Health

First Name*

Middle name

Last name*

Preferred name

Date of birth*

Sex*

Male
Female

Your primary health condition or reason for Weber Laser treatment?*

Current Medical conditions?*

Current medications, include medication name and dose?*

Please provide your current medical doctors details and any other practitioners treating the condition you are seeking Laser Therapy to assist?*

Have you been diagnosed with cancer?*

Are you currently pregnant, breast feeding or trying to conceive?*

Do you have a pace maker?*

Do you have any surgical implants?*

Do you have Haemophilia?*

Do you have epilepsy or suffer seizures?*

Do you take anticoagulants (blood thinners)?*

Do you take medications that promote photo-sensitising such as Roacutane?*

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

Preferred Contact Method

Do you consent to the following:

SMS appointment reminders
Email appointment and check-up reminders
Ballina Health Centre Newsletter emails

Email

Emergency contact person*

First Last

Emergency contact person address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency person phone number*

Emergency person phone number alternate

Relationship with emergency person

List any medications, foods or products you are allergic to (if none known please enter "Nil Known")*

Are your allergic reactions...

Mild
Moderate
Severe

Are you an Elite Athlete?

Yes
No

Clinic Policies - Management Of Your Personal Information*

Your health 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 - Cancellations*

We request that cancellation 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 laser therapists 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. 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 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

Additional comments - optional