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

0%


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

Male
Female

(dd/mm/yyyy)


Days, weeks, months or years

If so, please provide more information.

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