Medical Questionnaire

Medical Questionnaire
Personal Details
Name

First NameLast Name
Email
example@example.com
Mobile Number
Please enter a valid phone number.Format: 0000 000 000.
Date of Birth

DayMonthYear
Date
MaleFemale
Medicare Number (If you have no Medicare number, type PRIVATE)
Please enter your 10 Digit Medicare number
Address
YesNo
Please provide your delivery address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
YesNo

Thank you for your response.

Unfortunately, we cannot provide medical advice or prescribe medication to individuals under 18.

If this information is not correct, you can go back.
Thank you for your response.

Unfortunately, we cannot provide medical advice or prescribe medication to individuals who are professional athletes.

If this information is not correct, you can go back.

Your Blood test results are required
Based on your answers, you may qualify for our Testosterone Therapy program

Our doctors will need to review your blood test results to assess your current hormone levels and be able to offer you

The TIDES Clinic & Bloody Good Tests have developed a comprehensive male blood test that gives our prescribers a full picture to be able to create the perfect treatment protocol for you.
How it works:

1. Order your blood test
We’ll send you a link via SMS and EMAIL to order your blood test.

2. Get tested at a local lab
Take your electronic referral to any of the collection centres.

3. Results sent to TIDES Clinic
Your results are sent directly to our doctors.

4. Doctor consultation
Review results and discuss your plan.
To ensure your treatment plan is not delayed, ensure that you purchase your blood test referral and get a morning fasted blood test completed as soon as possible.

Book your Consultation call back

Select the best available time for our team to contact you directly, to discuss your previous answers and book in your appointment with our doctor.

Consent
I confirm the information provided is true and correct.I understand this is not a diagnosis and a clinician will review my responses before prescribing any treatment.I consent to being contacted by TIDES Clinic via phone, SMS or email regarding my consult and treatment options.
Signature
Should be Empty:

Your Blood test results are required