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Disclaimer - Pain 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

On a scale of 1-10, how would you rate your pain? (10 being the highest level of pain)
Have you previously been prescribed pain relief medication for this condition?
Have you used the medication before which you are requesting today?
Have you had your pain reviewed by your GP?
Do you understand that pain relief medication should be used short term. If you require this medication long term, we would encourage you to see your GP for a review.
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 my own regular doctor of
Would you like us to notify your GP of the medication you choose to order today?
Product
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