Your Consultation – mypharmacystop.com

What is your name ?

Country you are travelling to

What is the usual time difference between the UK and the country you are flying to?

Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?

Yes

In the last two months have you taken any medicine, including both prescription and non-prescription medicines, other than any medicine you have mentioned above?

Yes

Are you allergic to any of the following?

Please select all that apply.

Do you have any other known allergies?

Yes

Have you ever been diagnosed with a liver condition?

Yes

Have you ever been diagnosed with a kidney condition?

Yes

Have you ever had a serious brain injury, been diagnosed with epilepsy or suffer from seizures?

Yes

Have you ever been diagnosed with an autoimmune condition?

Yes

Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?

Yes

Informed consent

I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.
I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Lloyds Online Doctor before proceeding.
I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.

I confirm that I understand and agree to the above

Jet Lag