This form is designed to help us safely and effectively dispense your medicine. Please answer truthfully.

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If this is not for yourself, please can you tell us who it is for and their age. e.g. grandmother (79yrs old)

If so, please describe the symptoms for us

Please specify the numnber of days/weeks

This could be prescription medication, over the counter or herbakl remedies.

If so, please provide more information.



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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.