We will access your consultation upon receipt to determine the outcome
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If Yes please add additional details to box below
You have answered all the above questions accurately and truthfully. You understand our pharmacist's take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.
We need to ensure that this medicine is suitable for the person it is intended for. Therefore may be required to contact you by phone, If we are unable to speak to you when required your order may be delayed.
You will seek medical advice if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I confirm that I give permission for My Pharmacy 365 to inform my doctor of the treatment I have received if the prescriber feels it is clinically necessary