Questionnaire

Questions from our Pharmacist

As this is a Pharmacy Medicine, we need to ask you a few questions. These will help our Pharmacist ensure the product is right for you.

Patient details

Medication Form

What is the sex of the person(s) using this medication?
Male
Female

Is the medicine just for you?
Yes
No

What is the age, in years, of the intended user(s) of this product? Please give in months if younger than 1 year. *

Do you have any symptoms?
Yes
No

If Yes, how long have the symptoms been present?

Is the intended customer taking any other medication?
Yes
No

If yes, please provide more information:

Does the intended customer(s) live with any other medical conditions (e.g. diabetes, asthma)?
Yes
No

If yes, please provide more information:

What is your age?

I confirm that I have read the information in this questionnaire, product page, and will follow the advice shown here and in the product leaflet.
I confirm the information is correct.

Patient Details: Enter your EBay ID

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What is the sex of the person(s) using this medication? *

Male
Female

Is the medicine just for you? *

Yes
No

What is the age, in years, of the intended user(s) of this product? Please give in months if younger than 1 year. *

First

Last

What symptoms will the product be used to treat?

How long have the symptoms been present? *

First

Last

including user(s) of

Please provide any additional information that the pharmacist may need to know.

Is the intended customer(s) taking any other medication, including vitamins and herbal remedies? *

Yes
No

Does the intended customer(s) live with any other medical conditions (e.g. diabetes, asthma)? *

Yes
No

Consent

I confirm that I have read the information in this questionnaire, product page and will follow the advice shown here and in the product leaflet.

Email *