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?

Do you take any medication? This can be prescribed medication or any other over the counter or herbal medicines? Yes | No

If Yes Give Details

Have you had any Hayfever treatment before? Yes | No

If Yes Give Details

Have you ever been diagnosed with liver or kidney disease? Yes | No

If Yes Give Details

Are you pregnant or breast-feeding or intending either whilst taking treatment? Yes | No

If Yes Give Details

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? Yes | No

If Yes Give Details

Do you have any known allergies? Yes | No

If Yes Give Details

Do you have any other significant medical conditions that you think we should know about? (e.g. recent or major operations, porphyria, neurological conditions or mental health illness etc.) Yes | No

If Yes Give Details

Please provide any further information that you think will help our prescriber when reviewing this request for medication. (optional)

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?

To continue, please provide your GP's surgery address below.