Your Name:
Your E-mail:
Questionaire for :
Is this product for your own use?* YesNo
Who will be using this product?*
How old is the intended user?*(DOB) DD01020304050607080910111213141516171819202122232425262728293031/MMJanFebMarAprMayJunJulAugSepOctNovDec/
What will this product be used for?*
How long have the symptoms been present?* —Please choose an option—1-3 Days4-7 Days1-2 weeks2-3 WeeksMore Than 3 WeeksOn and Off For Weeks/MonthBuying In Advance
Is the intended user taking any other medication, or do they have any medical conditions, or do they suffer from any allergies?* YesNo
Please list the medication, details of condition, and/or allergies*
Please confirm the intended user agrees that:* All information provided is truthful and correct I will read the leaflet provided with this product and follow the instruction I will inform my GP that I am taking/using this product if needed I consent to being assessed and treated online via this platform I consent that I have risk assessed my chosen shipping address to ensure that there will be no access of this delivery from children, vulnerable individuals or pets