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Disclaimer - Hayfever Consultation Form

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.
 

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?
What is your Date of Birth?
Day
Month
Year
Have you been diagnosed with any medical conditions?
Have you ever been diagnosed with a mental health illness?

If Yes Give Details

If Yes Give Details


If Yes Give Details

If Yes Give Details

If Yes Give Details

If Yes Give Details

If Yes Give Details

Please select the symptoms that you suffer from. You can select more than one answer.
Please confirm the below; I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform
Would you like us to inform your GP?
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