Initial Pathology Questionnaire

Initial Pathology Request Questionnaire (2-3 mins to complete)

Name(Required)

Please enter your name as it appears on your Medicare card.

First Last

Date of birth(Required)

Phone(Required)

Please provide your best contact mobile number.

Email(Required)

We’ll use this email address to send you your pathology results and relevant updates.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please provide your 10-digit Medicare number (Required for eScripts and Pathology referrals)(Required)

To process your prescriptions efficiently, we require your Medicare Number. These details are necessary for our doctors to prepare and issue Pathology referrals.

Please provide your Medicare Individual Reference Number (Required for eScripts and Pathology Referrals)(Required)

Medicare Individual Reference Number (IRN) - the small number next to your name on your Medicare card PLEASE NOTE Reference number must be included with Medicare number)

What best describes your current situation?(Required)

I have never used Testosterone Treatment

I am currently prescribed testosterone by a doctor

I have previously been prescribed testosterone but no longer receiving treatment

I have used testosterone or other hormone-related medication without a prescription

Are you currently taking, or have recently taken, any hormone-related medications?(Required)

Yes

Unsure

This includes testosterone, anabolic steroids, hCG, fertility medications and medications intended to influence testosterone and/or other hormone levels.

Please list the medications, approximate doses and when you last used them.(Required)

Have you had your testosterone levels tested within the last three months?(Required)

Yes

Please upload your recent pathology results, if available

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 50 MB.

Official pathology reports in PDF format are preferred. If you don’t have them on hand you can provide them later.

Are you currently experiencing any of the following symptoms or concerns?(Required)

Please select all that apply. These symptoms can have several causes and do not necessarily indicate low testosterone

You selected Other, please specify.(Required)

How long have you been experiencing these symptoms?(Required)

Less than 3 months

3-6 months

6-12 months

More than 12 months

Do you have any diagnosed medical conditions or significant health concerns?(Required)

Yes

Please provide brief details of your medical conditions(Required)

Are you currently taking any prescription medications?(Required)

Yes

Please list your current medications and doses, if known.(Required)

Please include prescribed medications, not including hormonal treatments already mentioned, if applicable.

Do you have plans to have children in the future?(Required)

Yes, within the next 12 months

Yes, but not within the next 12 months

Unsure

Fertility intentions are relevant to any future discussion about testosterone treatment

Are you currently receiving medical care for testosterone or hormone-related concerns?(Required)

Yes

Please provide brief details of your current treatment or treating doctor/clinic

Is there anything else you would like our doctor to know before reviewing your request?

You may include any additional information you believe is relevant.

Patient Acknowledgement and Consent

Please read the following acknowledgment and consent section carefully before proceeding.

Patient Acknowledgement & Consent(Required)

I understand that the information I provide will be reviewed by an Australian-registered doctor to determine whether pathology testing is clinically appropriate and which tests may be required.

I understand that the $30 pathology referral fee covers the doctor’s review of my information and the preparation and delivery of a pathology referral, where clinically appropriate. Payment does not guarantee that I will be eligible for testosterone replacement therapy (TRT), or that medication will be prescribed.

I understand that additional blood testing may be required at a further referral fee of $30, and that any subsequent medical consultation is charged separately. I acknowledge that pathology providers may charge additional fees for tests that are not covered by Medicare.

Pathology Collection Centres

I understand that I may attend any pathology collection centre that accepts my referral. However, EliteTRT recommends attending a collection centre operated by the pathology provider listed on my referral to help ensure that my results are sent directly to the clinic.

If I choose to attend a different pathology provider, I understand that it is my responsibility to notify EliteTRT of the provider and collection date so the clinic can follow up and obtain my results.

Once my results have been received and processed by EliteTRT, a copy will be emailed to my nominated email address.

Pathology Referrals & Results

I understand that, where approved by the doctor, my pathology referral will be sent to the email address or mobile number that I have provided. I am responsible for attending a pathology collection centre and following any preparation instructions provided.

I understand that EliteTRT will generally receive my pathology results directly from the pathology provider. Once received and processed by the clinic, a copy of my results will be emailed to my nominated email address. I acknowledge that additional testing or medical follow-up may be recommended depending on the findings.

Privacy & Confidentiality

I understand that EliteTRT collects and handles my personal and sensitive health information for the purpose of reviewing my request, arranging appropriate pathology referrals, receiving results and communicating with me regarding my assessment.

I consent to my relevant information being shared with the treating doctor, pathology providers and other healthcare professionals involved in my assessment, where necessary.

I understand that pathology referrals, results and related communications may be sent to my nominated email address, and I consent to receiving these documents electronically.

I acknowledge that I have been provided access to EliteTRT’s Privacy Policy, which explains how my information is collected, stored, used and disclosed.

Declaration

I confirm that the information I have provided is accurate and complete to the best of my knowledge, and I understand that providing incomplete or inaccurate information may affect the doctor’s assessment.

I confirm that I have read and understood the information above, acknowledge EliteTRT’s Privacy Policy, and consent to the collection, use and disclosure of my personal and health information for the purposes outlined, including the electronic delivery of pathology referrals and results to my nominated email address.