BOOK A HAIR CONSULT BOOK A HAIR CONSULT Step 1 of 5 20% Requesting On Patient's Behalf As A Clinic?YES, REQUESTING ON PATIENT'S BEHALF AS A CLINIC YES, REQUESTING ON PATIENT'S BEHALF AS A CLINIC Clinic DetailsClinic Name(Required) First Consent(Required) I have permission from the patient to request a consultation on their behalf.Person In Charge Of Product Payment(Required) First Contact Number For Product Payment(Required)Patient DetailsPatient Type(Required) I am a new patient I am a returning patient Full Name(Required) First Last Your Email Address(Required) Your Phone(Required)Medicare Number(Required)How did you hear about us? Word of mouth Google search Instagram/Facebook Social media group If a phone call is required, what is the best time to call?(Required) 8am-10am 10am-12pm 12pm-3pm 3pm-5pm Tell Us More About You:Date Of Birth(Required) DD slash MM slash YYYY Please tell us your occupationPostal Address for delivery of products(Required) Street Address Suburb State Postcode Are You Pregnant/Breastfeeding/Trying To Conceive ?(Required) Yes No (Please note: If you become pregnant, please stop treatment and let our team know.)Please Specify Pregnant Breastfeeding Trying to conceive Undergoing fertility treatments Have you had a skin cancer checkup in the past 12 months?(Required) Yes No Tell us a little bit about your concernsWhich of the following best describes your hair changes? Gradually thinning over time Periodically experiencing large quantity hair loss events Unexpected, large quantity, one time hair loss event Please identify how you are experiencing the hair loss? Receding Hairline Bald patches Overall thinning How long have you been experiencing these changes? A few months 1-2 years > 2 years Are you aware of a family history of hairloss? Yes No Can you think of any tiggers that may have contributed to your hair loss? Tell us about your haircare journey so far:Have you ever been prescribed treatment for any of the following: Androgenetic Alopecia Alopecia Areata Telogen Effluvium Traction Alopecia Scarring Alopecia (Cicatricial Alopecia) Hypotrichosis Seborrheic Dermatitis Nutritional Deficiencies Thyroid Disorders Chronic Illness Other Please provide detailsHave you received any of the following treatments in the past? Minoxidil (Topical or Oral) Finasteride (Topical or Oral) Low-dose Naltrexone Ketoconazole Shampoo Biotin and Other Nutritional Supplements Corticosteroid/PRP Preparations Hair Transplant or Other Invasive Treatments Hormonal Treatments Other Please provide detailseg, effectiveness, allergies (symptoms of presentation), dosages and strengthsDo you use the following in your haircare routine? Shampoo Conditioner Hair Treatments/Serums Styling Products Other Please provide details of productsHave you ever had a reaction to a hair product or ingredient? If so, please specify and describe reaction:Current Medications and/or Medical ConditionsHave you ever had an allergic reaction to a medication? If so, please specify and describe reaction: Tell Us About Your Hair GoalsWhat improvements would you like to see?Are there any products or ingredients you would like to try?Note: We do not perform any hair treatments (IPL,transplant, PRP etc). If applicable and suitable, our doctors will prescribe topical and/or oral treatments only.Help us understand your situation betterPlease upload picture(s) showing your hair condition. Please upload ONE photo of your hair products in order of application. (ie. shampoo, conditioner, treatments, serums, styling) File Drop files here or Select files Max. file size: 10 MB. CAPTCHAConsent(Required) Please carefully read the privacy information below.I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of advice or treatment. I consent to My Skin Pharmacy using the information to provide the best possible outcome and I confirm that I have read and fully understand this consent form. Our doctors will only prescribe treatment if remote prescription treatment is safe and appropriate for you. A treatment is not guaranteed. In accordance with the privacy act (1988) all information collected is treated as "sensitive information". To protect your privacy, My Skin Pharmacy operates in accordance with the act. Australian Federal Privacy Laws require the pharmacy to receive your consent to collect your personal medical information.Your medical information will be used exclusively for the purpose of providing health care and treatment.Consultation Fee Price: Total
