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Born male
Born female



Don’t worry if it’s hard to fit everything in here; we’ll cover it all during the video consultation!




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Either prescribed or over the counter, including herbal remedies, supplements, or recreational drugs.


This may be to any medicines or other substances e.g. peanuts/soya)


Yes
No
Not Applicable

  • depression
  • generalised anxiety disorder
  • psychosis
  • schizophrenia
  • suicide attempts
  • suicidal thoughts
  • self-endangering behaviour or and other psychiatric disorder
  • epilepsy or convulsions of any origin?

  • Blood disorders such as thalassaemia or sickle cell anaemia
  • Kidney disease 
  • Liver disease 

If applicable, please describe the reaction you received.


If applicable, please describe the reaction you received.






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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • Y0u confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.

Please ensure the medication is stored safely out of reach of young children or pets to prevent accidental ingestion.


Please state your registered GP if you haven't done so already when signing up