headspace Ballarat Sexual Health Clinic
Request a Sexual Health appointment at headspace Ballarat by completing the questions below. We'll get in touch during business hours to confirm your request.
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Age
Phone Number
*
mobile preferred - we are unable to hold bookings without a valid phone number
Medicare Number
Enter your 10-digit Medicare number
Medicare expiry date
MM/YY
Address
Street Address
Street Address Line 2
City
State
Postcode
Appointment Times - select your preferred date and time
*
Submit
Should be Empty: