Pharmacist Advice Form

The Company | Health Advice | Online Shop

Confidential and Personal Information Sheet
To Be Completed For Pharmacist Advice Items

In the interest of your health this section must be completed by everyone ordering and using Pharmacist advice items.

The information you supply will be kept confidential, in accordance with our Privacy Policy. For more details or if you have any questions, please do not hesitate to contact us.

Name:
Email:

Medicine you wish to purchase:
Have you used this medicine before?
Have you previously supplied us with the information requested below?	If No skip the next question.
Has there been a change to those details?	If no, you needn't answer any further questions

Are you taking any prescribed medicines?
If so, please give details:
Are you taking any other medicines?
If so, please give details: eg. for headache, heartburn, etc. [ including herbal and complementary medicines.]

Age Band:
Weight:
Gender:
Pregnant?
How many months?
Breast Feeding:

I do not have any ongoing medical conditions or
Have an ongoing medical condition (please select all that apply)
Asthma or other lung condition	Depressive or other mental illness
High blood pressure	Stomach conditions (eg ulcers etc)
High cholesterol	Epilepsy
Diabetes	Glaucoma
Heart disease	Liver disease
Kidney disease	Arthritis
Thyroid disease	If other, please specify

As far as is know, I'm not allergic to any medicines or
Have known allergies to the following medicines
Penicillin	Aspirin
Tetracycline	Erythromycin
Codeine/Morphine	If other, please specify
Sulpha drugs

All Information will be held in strict confidence
and will not be supplied to anyone else.

Don't forget to complete your order.