Follow-up form

Follow-up form
Please use this form for your next follow-up consult with Dr. Binjemain or Dr. Xavier or our nurse Heidi. So that we can serve you better, please list the questions or issues that you want addressed. Bear in mind, often due to the complex nature of the questions and answers, please allow 15 minutes for each issue or set of questions.

Therefore, for 4 issues please allow 60 minutes. Typical follow-up consults take a minimum of 30 minutes, and up to 60 minutes. Fees are based on blocks of 15 minutes, at a rate of $150 per 15 minutes for Dr Binjemain, and $113 per 15 minutes for Dr. Xavier. In-person consults would attract Medicare rebates if you are eligible. Nurse Heidi's fees are $270 per hour (or $68 per 15 minutes)

Please fill out this form at least 48 hours BEFORE your appointment, as otherwise, we may have to reschedule your appointment.
Date

DayMonthYear
Date
Name*

First NameLast Name
Patient's Email*
example@example.com
Date of Birth*

DayMonthYear
Date
What medications or supplements are you taking currently?*
Question 1 *
Question 2
Question 3
Question 4
Any recent blood tests or imaging since the last consult? Please upload reports here

Please upload here
Cancelof
Should be Empty: