Pharmacy medicine check

For certain Pharmacy (P) medicines, our pharmacist must confirm suitability before we can supply. Please complete this short check. If we need more information, we will contact you. If we cannot confirm suitability, we will not supply and will refund the order.

Full name

Email

Phone number

Date of birth

Who is this medicine for?

Which medicine are you ordering?

What symptoms are you treating and how long have you had them?

What other medicines are you currently taking?

Do you have any medical conditions we should know about?

Include things like high blood pressure/heart conditions, thyroid problems, glaucoma, prostate problems, liver/kidney issues, breathing problems, or anything else relevant.

Have you used this or similar medicines recently?

I confirm the information provided is accurate and I consent to being contacted by the pharmacist if needed.