Your Contact Details

Questions

1. Do you have any known allergies or dietary restrictions?

2. Are you taking any other medicines from another pharmacy or store? (Including prescription or over the counter medicines, herbal products, or supplements bought in-store or online)

3. Do you have any current or previous medical conditions?

4. Please select which of the following applies to you:

5. What is your date of birth?

6. Is there anything about your health not mentioned above that you need to tell the pharmacist? (e.g. recent or upcoming surgery, medical tests, lifestyle changes such as diet or exercise, quitting smoking etc.)