Pharmacy Medicine Consultation Form

Please answer following questions...

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

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

Yes

Are you suffering symptoms?
If so, please describe the symptoms for us

Yes

How long have the symptoms been present?
Please specify the numnber of days/weeks

Are you taking any other medicines?
This could be prescription medication, over the counter or herbakl remedies.

Yes

Have you tried any other medicines to treat the condition already?
If so, please provide more information.

Yes

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