Wellness Infusion

Are you a new patient at Highgate Health? *

YesNo

Have you had an appointment with Highgate Health in last 4 Months? *

Yes NoNot Sure

Title *

Gender *

First Name *

Middle Name

Last Name *Please use legal name as per Medicare (No hyphens please)

Preferred Name

Date of Birth *

Mobile Number *no spaces please e.g. 0432123123

Email Address *

How did you hear about Highgate Health? *

Google.Facebook / Instagram.Friend.Referral from Medical Practitioner.Other.

Home address *Street address line 2

Suburb *

State *

Postcode *

Country

Do you have Medicare Card? *

YesNo

Medicare card number *

What number are you on the card? *

Important Information

We offer a range of Wellness infusions.

Please note any Infusions that you would that includes Vitamin C we need to rule out that you do not have G6PD this is done my a simple blood test. If you would like Vitamin C we are happy to provide a bulk billed consult.

Please go to this link to arrange the consult.

PLEASE NOTE for all infusions on Saturday there is an addional $15.00 AUD fee

Please select from the below *

I have had a G6PD test and would like Vitamin CI am happy to have the infusions without Vitamn CI am happy to have the first infusion without Vitamin C and would like you to collect a blood sample for future infusions to include Vitamin C

Which Wellness Infusions are you after? *

Myers CocktailPeonyRoseLotusTulip HydrateOther (We can discuss options with you during your infusion)

Please feel free to upload any other documents e.g. Pathlogy results or referral

Browse

Please add any documents now so they can be uploaded into your patient records

Any further information or comments.

I have read and agree to the :

Medical Practice Privacy and Telehealth Consent Form

Draw signature|Type signatureClear

For security please complete the check below *

Now to schedule the appointment.

Please wait, files are uploading..

This form is used using Snap forms their security policies and practices are based on ISO 27001, the Australian Government Information Security Manual, ACSC cyber security principles and guidelines including the Essential Eight Model, the Australian Privacy Principles and Privacy Act. Read more