Form submission | Pharmacy Bond

General medicine purchase questionnaire

First name

Last name

Birthday

Day

Month

Year

Please state the name of the medicine you intend to purchase.....

Is this for yourself or someone else?

myself

someone else

If it is intended for a child please state their age

Has the intended person used this medication before?

YES

NO

Does the intended person have any existing or chronic health conditions? (please state it even if you don't believe it to be relevant)

YES

NO

If yes please give more details.....

Does the intended person have any known allergies?

YES

NO

If yes please give more details.....

Is the intended person taking any other medications presently?

YES

NO

If yes please provide the names of the other medications

What do you intend to use this medication for?

To lower fever

for pain relief

other

If you have ticked other please provide more details.....

Please sign to state you have accurately answered all the above questions to the best of your knowledge

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Please note that once you submit the form, our pharmacist will review your answers and will either:

approve your purchase
call you to ask more questions or if unobtinable he/she may message or your email you (for the sake of promptness a phone call will always be our initial attempt)
reject your purchase and refund you

Our priority is customer safety

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