Please complete our medical questionnaire for women

Thank you for enquiring with Ashley and Martin. To enable us to organise your remote consultation, please fill in the medical questionnaire form below, this questionnaire is important so that our consultant and doctor can make the most accurate diagnosis and treatment recommendations.

Once your medical questionnaire has been submitted one of our consultants from our Medical Hair Centre will call you to set an appointment for a time and day convenient to you for the online consultation.

Remote Consultation Photos Requirements

Medical Questionnaire for Women 2

First Name: *

Last Name: *

Address: *

Town / Suburb *

Postcode: *

State *

Clinic ACT *

Clinic NSW *

Clinic NT *

Clinic QLD *

Clinic SA *

Clinic TAS *

Clinic VIC *

Clinic WA *

Email Address: *

Home Telephone:

Business Telephone:

Mobile Phone: *

Occupation *

Date of Birth *

Marital Status *

Gender *

Please take photos as instructed here, and upload each of the five required photos using the upload function below.

Upload five photos taken as per instructions above

Maximum file size: 134.22MB

How long ago did you first notice excessive hair loss or thinning? *

How long have you been considering any form of hair treatment or replacement? *

Have you previously taken steps to treat your hair loss or scalp problem? *

Have you also tried or sought advice from any of these other sources? *

Over the counter products

Medical treatment

None

Medicare Number:

Valid to:

Medicare Ref:

Signature *

Clear

Date

If you are human, leave this field blank.

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