Online Hair Assessment

Which one of these closest represents your current hair?*
- One
- Two
- Three
- None of these

Any other relevant comments regarding your hair loss condition? (Optional).
You may skip if you wish to only discuss your concerns with our qualified health practitioner during your consultation.

Which state/territory are you located in?*
Do you have Medicare?*
- Yes
- No
Note: If no Medicare details are provided, please keep in mind that the consultation will have a fee of $40. If you have Medicare, please provide the details in the next section so that you will not be out of pocket for the consultation.
Medicare Card Details*
Medicare Number Reference Number Name on your Medicare Card Expiry Date (MM/YYYY)
Address*
Street Address Address Line 2 Suburb State / Province / Region ZIP / Postal Code

We will need your address as per your Medicare details in order to bulk-bill your service.

Your email address will be utilised to create a convenient online account for purchasing any prescribed medications recommended by our doctor.
After your consultation with our doctor, you will be emailed a link within 48 hours to reset your password for your online account and instructions to purchase your prescribed medications.
Should you prefer not to have an account set up on your behalf, kindly inform us via email at info@bioscor.com.au

Do you CONFIRM that the information you have given is TRUE and ACCURATE, and that if prescribed a medication, this medication is solely for yourself, and that you will review the information supplied regarding the medication and possible side effects?*
- YES
- NO

Hair Questionnaire