To make sure this treatment is safe for you to take, we just need you to answer a few questions.(Please Note: The final decision to approve and supply treatment is made by our pharmacist so please make sure your answers to the following questions are as accurate as possible.)

Question 1

Who will be using this medication?

Myself Other

Question 2

What is the gender of the person using this medication?

Male Female

Question 3

What is the age of the person using this medication?

18-40 41-65 Over 65

Question 4

Please tell us what medical condition and/or symptoms this product is being used to treat

Question 5

How long have these symptoms been present?

Less then a week 1-3 weeks Over 3 weeks

Question 6

Please tell us about any existing medical conditions the person(s) has using this medication

Question 7

Please list any medication(s) being taken by the person(s) going to use this medication

Question 8

To help us reduce any delays in confirming your order, please leave any additional comments or information that the pharmacist may need to know

Question 9

We may require proof of Identity to authorise your order. If you fail to provide this information upon request your order will be rejected.

OK

I will read the Information Leaflets & follow the manufacturer's directions
Submit