Hair Loss Check Patient Rego Form

First Name*

Surname*

Date of Birth*

Email*

example@example.com

Mobile Phone Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have a Medicare Card?*

YesNo

Medicare Card Number

Medicare Card Line Number (Which Number are you on the card)

Medicare Card Expiry Date

If you do not have a Medicare Card we will need your Individual Health Identifier (IHI). This is available to everyone, including those people without a Medicare card. Without an IHI we are unable to send your prescriptions electronically to your phone or email.
For information on how to apply for an IHI go to Services Australia

What is your Individual Health Identifier (IHI)?

Do you have any medical conditions?*

NoYes

Please advise your medical conditions

Do you take any medications?*

NoYes

What medications do you take?

Do you have any drug allergies eg. pencillin?*

NoYes

Have you tried any of the following for your hair loss?*

FinasterideMinoxidilI have not tried anything for my hair lossOther

How long having you been on these treatments?

Less than 1 yearGreater than 1 year

We will usually provide you with a 12 month prescription for Finasteride. There are 2 choices for how we prescribe it. Please select which you prefer*

1mg Tablet. Take 1 a day. Cost ~ $30 per month5mg Tablet. Take 1/4 of a tablet daily. You will need pill cutter to quarter the tablets. Cost ~ $8 per month

What drugs are you allergic to?

Please take a photo of your scalp so we can assess your hair loss

Payment Details*

Hair Loss Check - Consultation and Prescription Product Image

Hair Loss Check - Consultation and PrescriptionComplete our online registration and consultation and we will assess your hair loss and offer a prescription for medication to help slow the loss and in some cases grow your hair back

$75.00AUD

Total

$0.00AUD

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

HairLoss Check