The commission will endeavour to contact you at your preferred time but it may not always be possible
Confirmation Required
If you proceed with an order, our doctor will call you on the below number to explain potential side effects and answer any questions you may have. Please ensure that your phone number is correct as the doctor cannot write a prescription without speaking with you first.
Answer some quick questions about your general health to get the most effective clinically proven treatments for you.
DO YOU AGREE AND CONSENT TO THE FOLLOWING?- I live in Australia.
- I shall be the sole user of any medication offered to me through this service.
- I confirm all answers are provided by me, and will be truthful.
- I agree to the terms and conditions.
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1
Would you like to skip the questionnaire and speak with a Doctor instead?
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2
Do you take any regular medications, have any known allergies or any medical issues?
3
Please list any regular medications you take, any known allergies or any medical issues.
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1
Do any of the listed medical conditions apply to you? *
- Do you have repeated severe headaches, often on one side, and/or pulsating, causing nausea, and which are made worse by light, noise, or movement?
- Are you currently breastfeeding?
- Have you ever had a stroke, blood clot in your legs or lungs, or heart attack?
- Have you ever been told that you have a rheumatic disease such as lupus?
- Are you a smoker over 35 years of age?*
- Have you been diagnosed with Migraine with Aura? *
2
Do any of the following apply to you?*
- Do you regularly take any pills for tuberculosis (TB), seizures (fits), or ritonavir for ARV therapy
- Have you ever been told you have breast cancer or do you have an undiagnosed breast lump?
- Do you have gall bladder disease or serious liver disease or jaundice (yellow skin or eyes)?
- Have you ever been told you have high blood pressure?
- Is there any abnormal vaginal bleeding including bleeding or bleeding during intercourse?
- Is there any chance that you are pregnant?
3
Have you recently had your blood pressure checked?*
4
What was your recent blood pressure reading?*
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10
Please enter your height in centimetres and weight in kilograms? *
cm
kg
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5
Did your last menstrual period start within the past 7 days?
4
Have you abstained from sexual intercourse since your last menstrual period or delivery?*
5
Have you had a miscarriage or abortion in the last 7 days?*
6
Is there any history of PCO/Endometriosis? *
7
Have you been using a reliable contraceptive method consistently and correctly?*
8
What brand of pill have you been using? Any side effects?*
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9
What brand of pill are you after?*
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10
Is there anything you would like to tell your Doctor?*
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11
Do you acknowledge that taking the pill still has the risk of falling pregnant, there is no protection against STD, and you need to follow up with your GP for BP/Weight check and Smear test. You also need to read the potential side effects of the pill from product information*
12
Discretion is at the heart of what we do but for legal reasons the name on your prescription must be your full legal name. Please provide your legal name as per your official government ID. *
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13
Please enter your date of birth. *
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Please use this format (DD/MM/YYYY)
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14
Based on your medical history and individual needs, our doctors have provided personalised treatment. Please complete your mobile phone number to view recommended treatment. *
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15
Do you have a Medicare card?
16
Please enter your Medicare Card details
/
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16
What is your IHI?
Your IHI is located next to your Covid vaccine certificate. If you are an international student or working visa holder, for our doctors to write a prescription, you first need to register for myGov and an IHI (Individual Health Identifier). You can do this all online within minutes. Please take a look at the Services Australia website for complete instructions, click here.
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4
Do you have a medication preference?
5
Enter the name of medication below
6
Please select your preferred strength
7
Have you taken 100mg before?
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6
How many uses?
7
Do you prefer?
Unfortunately based on your answer you would not be suitable for treatment. If you would like to speak with the Burst doctor to discuss other treatment options, please book an appointment here.
If you made a mistake, you can go back and correct your answer.
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Please follow this link to book a $35 consultation with our doctor:
Click here to book If you made a mistake, you can go back and correct your answer.
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Thank you for filling out the form.
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