1.1 – Personal Details
1.2 – Contact Details
1.3 – Medicare Details
Hair Loss Management: Patient Eligibility Form
About Your Hair Loss
Medical Information
PATIENT INFORMED CONSENT FORM

Hair Loss Management Programme

1. Introduction

This Informed Consent Form (‘Form’) documents your voluntary agreement to participate in the Hair Loss Management Programme (‘Programme’) at Optivital Health, prepared in accordance with AHPRA, TGA, and Privacy Act 1988 (Cth) requirements. By signing, you confirm you have received sufficient information, had your questions answered, and are consenting freely and voluntarily.

2. About the Programme

This Programme provides medically supervised assessment and treatment of hair loss via telehealth. Medications commonly prescribed include topical minoxidil, oral minoxidil (low dose), and finasteride, or combination approaches as determined by your treating practitioner. Hair loss treatment requires long-term commitment; results typically take 3–6 months to become apparent and cessation of treatment usually results in return of hair loss within 6–12 months.

3. Regulatory Status

Some medications prescribed under this Programme may be compounded formulations and therefore unapproved therapeutic goods under the Therapeutic Goods Act 1989 (Cth). Oral minoxidil is used off-label for hair loss. Where applicable, your treating practitioner holds the relevant TGA authority. TGA-registered alternatives will be discussed where available.

4. Material Risks and Possible Side Effects

4.1 Minoxidil (Topical and Oral)

  • Initial increased hair shedding in the first 4–8 weeks (expected and temporary);
  • Scalp irritation, dryness, or allergic contact dermatitis (topical); and
  • For oral minoxidil: fluid retention, palpitations, or lowered blood pressure — cardiovascular monitoring required.

4.2 Finasteride (Male Patients Only)

  • Reduced libido, erectile dysfunction, or ejaculatory disorders in approximately 2–3% of patients;
  • Post-Finasteride Syndrome (PFS) — a subset of patients report persistent sexual, mood, and cognitive symptoms after cessation. Incidence and mechanism remain under investigation;
  • Gynaecomastia in a small number of patients;
  • Finasteride lowers PSA — inform any doctor conducting PSA testing; and
  • Absolutely contraindicated in women who are pregnant or may become pregnant (TGA Category X).

4.3 Baseline Documentation

Your baseline sexual function and mood have been documented prior to commencement of finasteride. Notify your treating practitioner immediately if you notice any new or worsening sexual, mood, or cognitive symptoms after starting finasteride.

5. Monitoring Requirements

  • First follow-up consultation: 1 week post-consult (check-in); 30-day follow-up prompt;
  • Recall-based consultations at 14-day, 70-day, and 160-day milestones (or as per doctor’s instruction); and
  • Medication check-in 2 weeks before projected supply exhaustion.

6. Alternative Treatments

Alternatives include low-level laser therapy (LLLT), platelet-rich plasma (PRP) injections, hair transplant surgery, and nutritional supplementation for deficiency-related hair loss. Your treating practitioner can discuss these options with you.

7. Patient Responsibilities

  • Apply or take medication strictly as directed;
  • Attend all scheduled follow-up consultations;
  • Report any new or worsening sexual, mood, or cognitive symptoms immediately (particularly with finasteride);
  • Inform your GP of all medications received under this Programme; and
  • Female patients: do not handle crushed or broken finasteride tablets if pregnant or planning pregnancy.

8. Telehealth Consultations

  • You are responsible for ensuring you have a stable internet connection, a functioning device with a camera and microphone, and are in a private location at the time of your consultation;
  • If a technical failure occurs that prevents the consultation from proceeding, our team will contact you to reschedule at the earliest available time;
  • Telehealth consultations do not permit physical examination. Your treating practitioner will rely on your self-reported symptoms, uploaded documents, and pathology results. You must disclose all relevant information accurately.
  • If at any point your condition requires in-person assessment or emergency care, you must present to an appropriate healthcare facility immediately.

9. Payment and Fees

  • Consultation fees are due at the time of booking or as otherwise communicated by Optivital Health. Fees are non-refundable once a consultation has been attended;
  • Medication costs are separate from consultation fees and are invoiced at the time of prescription processing. Costs vary by formulation and dosage as determined at each consultation;
  • Some pathology tests required under this Programme may not be bulk-billable and may incur an out-of-pocket fee. Your clinical team will advise you in advance where this applies.

10. Cancellations and Rescheduling

  • You must provide at least 48 hours’ notice to cancel or reschedule a consultation. Notice can be provided by replying to your appointment confirmation email or by contacting the clinic directly;
  • Cancellations with less than 48 hours’ notice, or failure to attend without notice (no-show), may incur a cancellation fee as communicated in your booking confirmation;
  • Where a consultation is cancelled by Optivital Health (e.g., due to practitioner unavailability), you will be offered a rescheduled appointment at no additional cost.
  • Repeated cancellations or no-shows may affect your continued participation in the Programme at the discretion of the treating practitioner.

11. Privacy

Your personal and health information is collected, used, and stored in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles (APPs). It is used to provide clinical care, facilitate prescription processing and dispensing, and support continuity of care. Your information will not be disclosed to third parties without your consent except as required by law (e.g., mandatory reporting obligations, court orders, or TGA reporting requirements under applicable Authorised Prescriber conditions).

You have the right to access and correct your personal information held by Optivital Health. To make a request, contact the clinic directly. Our full Privacy Policy is available on request.

12. Right to Withdraw Consent

You may withdraw your consent to the Hair Loss Management Programme at any time without penalty by notifying your treating practitioner. Withdrawal will result in cessation of your treatment plan. Where clinically appropriate, your practitioner will advise on any recommended transition or tapering protocol. Withdrawal does not entitle you to a refund of consultation or medication costs already incurred.

13. Patient Declaration

I declare that I have read and understood this Form in full; my questions have been answered to my satisfaction; I understand the nature, purpose, risks, and limitations of the Hair Loss Management Programme; I have disclosed my full medical history and all current medications and supplements; I understand my responsibilities including attendance, monitoring, and payment obligations; and I am consenting freely and voluntarily to proceed at Optivital Health.

3.1 – Confirmation
Confirm you are ready to finalise and submit this form to your practitioner.