Complete Your Questionnaire
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Your Details
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Step
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of 2
First Name
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Last Name
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Email Address
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Phone Number
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Date of Birth
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Height
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Weight
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Next
Are you over 18 years of age?
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Yes
No
Are you currently pregnant or breastfeeding?
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Yes
No
Not applicable
Have you been diagnosed with cancer in the past 5 years or are you currently undergoing treatment?
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Yes
No
Are you currently located in Australia and able to attend telehealth consultations with an Australian doctor?
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Yes
No
Would you like UHD to prepare your proposed pathway and quote?
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Yes - prepare it from my answers and email me firstEmail me a proposed pathway/quote first
I would prefer a phone call firstI would prefer a phone call before anything is prepared
UHD uses your answers to build a proposed protocol and support package for you to review. It still requires doctor consult and clinical review before pharmacy can proceed.
I understand this is a request for pathway support, not medical approval.I understand UHD will review this request and may prepare a proposed pathway for me to review. This is not a prescription, medical approval or guarantee of treatment. Any treatment request still requires a doctor consult/review before pharmacy coordination can occur.
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Yes, I understand and want UHD to review my requestYes, I understand and want to submit my request
I need more information firstI need more information first
UHD can help organise a proposed pathway on your behalf. A doctor must still consult, review your details and decide clinical suitability.
Which pathway would you like UHD to build your request around?
Weight Management
Recovery and Injury Support
Performance and Recovery
Healthy Ageing
Energy and Vitality
Sleep and Stress
Choose the main area you want help with. You can add specific treatment interests in the notes field below.
Previous treatment experience
New to this pathway
Previously prescribed treatment
Currently using prescribed treatment
Tell us whether you are new to this pathway or have used prescribed treatment before.
What budget range should we work within for your proposed protocol?Preferred budget per proposed protocol
Under $250 per protocol
$250 to $500 per protocol
$500 to $750 per protocol
$750 to $1000 per protocol
$1000+ per protocol
This helps us avoid preparing something that does not suit your budget. It is not a lock-in. Final costs depend on doctor review, dose, treatment type and pharmacy pricing.This helps UHD prepare a proposed pathway close to your expected budget where possible. Final costs depend on doctor review, dose and pharmacy pricing.
Medical history flags
Complex medical condition or specialist care
Recent hospitalisation or major surgery
Current prescription medications
Prior side effects or treatment concerns
None of these apply
What do you want help with, and is there anything specific you want considered?Tell us what you want your proposed pathway built around
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Tell us your main goal, the issue you want addressed, treatment names you have heard of, previous experience, current medications, allergies and anything important for UHD or the doctor to know.Include the main issue you want addressed, any treatment names you have heard of or want discussed, current medications, allergies, previous treatment experience, and anything UHD or the doctor should know. Write none if not applicable.
Medicare number
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Required for doctor review and eScript preparation if your request progresses.Enter your Medicare card number if available. This helps UHD prepare doctor intake details if your request progresses.
Medicare expiry
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Required for doctor review. Enter the month and year shown on your Medicare card.Month and year on your Medicare card, if available.
Medicare IRN / position number
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Required for doctor review. This is the number beside your name on the Medicare card.The number beside your name on the Medicare card, if available.
Final consent and acknowledgementsConsent and acknowledgements
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I confirm the information I have provided is accurate and complete to the best of my knowledge.
I understand UHD BioHealth is a telehealth pathway support service and this form does not replace medical advice, a doctor consult, or clinical assessment.
I understand UHD may prepare a proposed protocol and support package for me to review, but treatment is not guaranteed and remains subject to doctor consult, clinical review and pharmacy availability.I understand any proposed pathway is subject to doctor consult/review, clinical suitability and pharmacy availability. Treatment is not guaranteed.
Please read and tick each acknowledgement before submitting your request.
Patient signature
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Clear Signature
Please sign to confirm the information and consent acknowledgements above are true and understood.
Full legal name
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Type your full legal name to match your signature and submission details.
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