Cold Sore Questionnaire

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 seven 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
Please provide your sex at birth*
2
Has a Doctor previously diagnosed you with (Herpes Sim-plex Virus)?*
3
Do you know what type of HSV you have?*
4
Are you having an out break at the moment?
5
How often do you have outbreaks in 12 months Period?*

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6
Have you used Antiviral Medication before to manage outbreaks?
7
What medications have you used before to manage outbreaks?*

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8
Did you have a good result from treatment?
9
Did you experience any side effects?
10
What side effects did you experience?*

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11
Are you currently taking any medication?
12
What medication are you currently taking?*

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13
Do you have any allergies?
14
What allergies do you have?*

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15
Do you have any medical conditions or a history of prior surgeries?
16
What are your medical conditions and history of prior surgeries?*

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17
Is there anything else you want your Doctor to know about your condition or health?
18
What would you like to tell your Doctor?*

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19
Is there any chance that you are Pregnant?
20
Would you like to have the medication for treatment of your current symptoms or for prevention of future flare up?*
21
Can you confirm that the information you have given is true and accurate, that this medication is solely for yourself, and that if prescribed the medication, you will review the information supplied regarding the medication and side effects.
22
Please enter your date of birth. *
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Please use this format (DD/MM/YYYY)
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23
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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24
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?
15
Please enter your Medicare Card details
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15
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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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.

It has been sent to our doctor for review.

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