P Line Consultation Form

Please answer following questions...

This form is designed to help us safely and effectively dispense your medicine. Please answer truthfully.

Who is it for?
Is this medicine for yourself or another person?

Self

Family Member

Are you ordering this medication for yourself?

Yes

Are you suffering symptoms?
If so, please describe the symptoms for us

Yes

How long have the symptoms been present?

Days

Weeks

Months

Years

Are you taking any other medicines?
Including herbal remedies. If So, please provide more information.

Yes

Have you tried any other medicines to treat the condition already?
If so, please provide more information.

Yes

Pharmacy Medicine Consultation Form