Hair Loss Check Patient Rego Form

  • HairLoss Consultation

    Registration and Payment Form
  • Do you have a Medicare Card?*

  • 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

  • Do you have a GP who you would like us to tell about any treatment we provide?*
  • Do you have any medical conditions?*
  • Do you take any medications?*
  • Do you have any drug allergies eg. pencillin?*
  • Have you tried any of the following for your hair loss?*
  • How long having you been on these treatments?
  • We will usually provide you with a 6 month prescription for Finasteride. There are 2 choices for how we prescribe it. Please select which you prefer*
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  • Payment Details*

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    Hair Loss Check - Consultation and Prescription. Complete 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
    Hair Loss Check - Consultation and Prescription

    Complete 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

    $65.00 AUD$65.00AUD
      
    Total
    $0.00 AUD$0.00AUD
    Payment Methods

  • Assignment of Medicare Benefit (Bulk Billing)
    I understand that Men's Health GP (or the treating practitioner) intends to bulk bill the Medicare benefit for the professional services provided during this consultation.

    By submitting this form, I:

    - Assign my right to the Medicare benefit to the health practitioner.
    - Agree to accept the relevant Medicare benefit as full payment for the service.
    - Understand that a copy of the completed Assignment of Benefit form (or a summary of the service) will be provided to me electronically via my nominated email address.

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