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All information is confidential and will be reviewed by Australian Registered Doctor
PLEASE CALL OUR DOCTOR'S ASSISTANT TO DISCUSS ON 1800 200 500
Part 2 of 3
IF A DOCTOR DETERMINES THAT YOU ARE SUITABLE AND PRESCRIBES MEDICATIONS FOR YOU, IT WILL BE DISCREETLY DELIVERED TO THE ADDRESS PROVIDED BY YOU. PLEASE PROVIDE YOUR CONTACT DETAILS FOR DELIVERY.
WE ALSO FOLLOW UP ON OUR PATIENTS TO MAKE SURE THEY GET GREAT RESULTS
Complete - Please review the following details before you submit your details:
Item | Response |
---|---|
DATE OF BIRTH: |
{{contact.dateOfBirth}} |
ARE YOU DIAGNOSED WITH ANY CHRONIC OR ONGOING MEDICAL CONDITIONS? |
{{contact.medicalConditions}} |
ARE YOU AWAITING TEST RESULTS OR REFERRAL TO ANY SPECIALISTS? |
{{contact.specialists}} |
ANY KNOWN ALLERGIES TO MEDICATIONS? |
{{contact.medications}} |
ARE YOU CONCERNED ABOUT YOUR SEXUAL ABILITY OR PERFORMANCE? |
{{contact.ability}} |
IN YOUR OWN WORDS PLEASE DESCRIBE: |
{{contact.comments}} |
Appointment Date: |
{{contact.appointDate}} |
Appointment Time: |
{{contact.appointTime}} |
YOUR NAME: |
{{contact.fullName}} |
YOUR EMAIL: |
{{contact.email}} |
NUMBER WE CAN REACH YOU ON: |
{{contact.number}} |
{{controls.response.message}}
*TO HAVE A CONFIDENTIAL CONSULTATION WITH AUSTRALIAN REGISTERED DOCTORS OVER THE PHONE OR VIDEO LINK PLEASE CALL US NOW ON: 1800 200 500