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?

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 a GP who you would like us to tell about any treatment we provide?

GP Name

GP Clinic Name

Do you have any medical conditions?

Please advise your medical conditions

Do you take any medications?

What medications do you take?

Do you have any drug allergies eg. pencillin?

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

Other

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

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

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

Total

Payment Methods
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

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.

HairLoss Consultation

Payment Details*

Payment Details