Who is the medication for (Age) ?

What are the Symptoms ?

How Long have you had the symptoms for?

Are you taking any regular medication? (Prescription medication/ Over the counter Medication)

Have you tried any medication for your current symptoms ?

• To read the patient information leaflet this will be given to you with your medication
• To keep us and your GP informed when you start a new medication, if your medical condition changes during treatment or if you experience any side effects of treatment.
• That the medication we supply you with will be only for your own personal use.
• That you have answered the above questions truthfully and accurately. Our prescribers base their prescribing decisions on the answers you give and that any information you have provided that may be incorrect could have a detrimental effect on your health.
• I declare that the information I have supplied is both complete and truthful and I agree to read the patient information leaflet provided before using this medication.*
• I declare that I agree with the Customer Responsibility Statement*
• I declare that I agree with the Informed Consent Agreement*
• I declare that I agree with terms & Conditions and Privacy Policy

You must agree to this before continuing.