Pharmacy Medicine Consultation Form

Please answer following questions...

If so, please describe the symptoms for us

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

What is your symptoms?

If so, please describe the symptoms for us

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 herbal remedies.

Yes

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

Yes

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