Eligibility Assessment Form

Before booking your telehealth consultation with Balnce, please complete this quick eligibility check. The form will ask for your name, email, phone number and preferred time for a call. Once submitted, our team will contact you at your selected time to assess whether alternative medicine treatment may be suitable for your needs.

First name: *

Last name: *

Mobile *

Email: *

Preferred date for a call *

Preferred time for a call *