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

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If this is not for yourself, please can you tell us who it is for and their age. e.g. grandmother (79yrs old)

If so, please describe the symptoms for us

Please specify the numnber of days/weeks

This could be prescription medication, over the counter or herbakl remedies.

If so, please provide more information.