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.
press Enter ↵
1
Pregnant or breastfeeding? *
2
Enter details of any allergies *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
3
Enter details of any medical conditions *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
4
Enter details of any medications you are currently taking or have recently taken *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
5
Based on your medical history and individual needs, our doctors have provided personalised treatment. Please complete your mobile phone number to view recommended treatment. *
press Enter ↵
6
Please enter your date of birth. *
/
/
press Enter ↵
7
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. *

Shift ⇧ + Enter ↵ to make a line break

press Enter ↵
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.
press Enter ↵
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.
press Enter ↵

Thank you for filling out the form.

It has been sent to our doctor for review.

0% completed