Register - Vitahealth Clinic

Personal Information

First Name

Last Name

Username

Email

Password

Confirm Password

Are you over 18 years old?

Yes

What gender were you assigned at birth?

Male
Female

Date of Birth

Contact Number

Identification DocumentUpload a clear image or PDF of your personal ID, passport, or other official identification.

Choose files

Treatment SelectionWhich medical solution are you interested in?

Goals/IndicationWhich areas of your health are you looking to improve?

Medical Screening

Are you pregnant?Or plan to be in the next 3 months?

Do you have a history of cancers or tumours?

Do you have a history of heart, kidney or liver failure?

Have you suffered from anxiety, low mood or even depression?

Have you ever had psychological counselling or drug treatment for mood disturbance?

Do you feel refreshed when you wake up in the morning and eager to get on with the day ahead?

How would you rate your current mental and emotional state?

Do you have difficulty getting to sleep or staying asleep?

Pathology ReportPlease upload your pathology report in PDF or image format. This is a compulsory requirement for Hormone Therapy.

Choose files

Medical DocumentationPlease upload medical imaging reports, specialist referrals and any other medical documents. If you have multiple documents please email them to - medical@vitahealthclinic.com.au

Choose files

Additional Information

AcknowledgementI confirm that the above information is correct and accurate to the best of my knowledge. I also accept that Vitahealth Clinic holds the right to refuse medical treatment if suitability requirements have not been met. I understand that a member from Vitahealth Clinic Care Team will be contacting me to confirm the information on this registration form, prior to deeming me elibigible for my chosen medical treatment.

Eligibility Questionnaire

Personal Information

Medical Screening