Online Hair Assessment | Bioscor International

When did you start losing hair?*
- In the last 6 months
- In the last 12 months
- 1-5 years ago
- 5+ years ago

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

What was the rate of your hair loss?
- Rapid
- Gradual
- Fell out in patches
- Other
Other - please describe

Do you have any known illnesses/conditions or have had any recently surgery?
If none, leave blank.

How effective was the treatment?
- Very effective
- Somewhat effective
- Not effective at all

Are you currently on any other medications or supplements? (not for hair loss)*
- No

Given the choice of hair loss treatment, I would prefer:
- Topical Solutions
- Oral Tablets
- Whatever I need for the best results

If convenient, please upload a photo of your hair for our doctor to see.
Please ensure the photo is clear.
Drop files here or

Accepted file types: jpg, png, Max. file size: 120 MB.

Full Name*
First Name Last Name
Mobile Number*
Email*

[email protected]
Which state/territory are you located in?*
Do you have Medicare?*
- Yes
- No
Please note: If no Medicare details are provided, please keep in mind that the consultation will cost $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.

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