To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

0%

Male
Female
Transmale (Born a female)
Transfemale (Born a male)


On a scale from 0 to 10, how would you rate your current pain level? (0 being no pain and 10 being the worst pain imaginable)

0
1
2
3
4
5
6
7
8
9
10

Head
Neck
Shoulders
Back
Arm
Leg
Other (please specify)

Less than a day
1-3 days
4-7 days
1-2 weeks
More than 2 weeks



Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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If yes, please provide more information listing the conditions.


If yes, please list your allergies.

If yes, please list your current medications.




Yes
No
Not Applicable



0%



- I am between the ages of 18 and 75.

- This treatment is for my use only.

- I have the capacity to make decisions about my own healthcare.

- I have understood all the questions and have answered this consultation truthfully and completely.

- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health.

- I will read the patient information leaflet supplied with this medication.

- I will contact [pharmacy-name] and inform my GP if I experience any side effects from this treatment or if there are any changes to my health.

- I have read, understood, and agree with the Terms and Conditions.