Pharmacy Only Questionnaire

Have you read the information, including the product information leaflet, on the product page and made yourself familiar with this medicine so you can ensure it's used properly? *

Yes
No

Please confirm that this medicine will be used following the instructions stated, and for the purpose that it is intended for. *

I confirm

Who will use this medicine? *

Myself
Someone else

How old is the person who will use this medicine? *

Will the user of this medicine be: *

Male
Female

Is the person who will use this medicine pregnant? *

Yes
No

Is the person who will use this medicine breastfeeding? *

Yes
No

What is this medicine be used for? *

Please be as specific and comprehensive as possible regarding symptoms and when they started.

If you are buying more than one pack of this item, please state the reason for this. (Leave blank if you are only purchasing one pack).

Does the person who will use this medicine have any known medical conditions? *

Yes
No

(Please note that this includes all conditions, even if you feel that they are irrelavent)

If yes, please state the condition(s) below

Is the person who will use this medicine currently taking any other medication? *

Yes
No

If yes, please list the treatment(s) below:

(Please note this refers to all treatments, even treatments such as inhalers, herbal products, over-the-counter items and supplements)

Does the person who will use this medicine suffer from any known allergies or intolerances? *

Yes
No

If yes, please list the known allergies/ intolerances in the space below.

If you wish to upload any photos or documents that are relevant to your condition, you can do so by clicking on the button below

Please state any other information you feel is relevant below

Examples of items you may wish to upload are the following:

A photo of the condition. This may be suitable if your condition can be visably assessed by the pharmacist such as a heat rash, or ringworm.
Documents which state the recipients current condition(s) or treatments.
Advisory medical letters/ slips
Pictures of previous treatments or their packaging.

Please upload a selfie of yourself holding a picture ID. (This is only used for the purpose of ID verification) *

Thank you for answering the above safety questions. What is the best means for the Goodcure pharmacist to contact you, should they require further information? Please tick one or more of the options below. *

Phone
SMS
WhatsApp
Email

Contact number *

Email address *

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