Clinical Consultation Form

EU Regulated Medical Service & Oversight

1 Patient
2 Intake
3 History
4 Consent
5 Submit

Step 1: Patient Information

First name is required.
Last name is required.
Please enter a valid Date of Birth. Must be over 18 years of age.
Please specify your biological sex.
A valid email address is required.
Phone number is required.

Step 2: Medical Intake

Please select the condition area.
Please provide symptom details.
Please select a duration.

Step 3: Clinical Suitability & History

Please answer this question.
Please select yes or no.
Allergy details are required.
Please select yes or no.
Existing condition details are required.
Please list your medications or enter 'N/A'.

Step 4: Declarations & Consent

Clinical Declarations
  • I confirm that the personal details and medical history provided in this form are true, accurate, and complete.
  • I understand that omitting information or providing false statements could have severe health consequences and will void any prescription.
  • I agree that my consultation results will be evaluated by The Care Pharmacy clinical team in accordance with EU pharmacy regulation guidelines.
  • I confirm that I am at least 18 years old and consent to my data being processed confidentially for clinical screening.
You must agree to the declarations to proceed.
You must accept the Terms and Conditions to proceed.

Consultation Form Submitted!

Your details have been securely recorded. Our clinical prescribers will evaluate your information shortly to approve your eligibility.

What happens next?
  1. Our pharmacists will review your suitability.
  2. You will receive a email notification once approved.
  3. Upon approval, you can safely complete your treatment purchase in our store.
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