Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient InfoGive us some information about yourselfFull Name *FirstLastEmail *Phone *Date of Birth *Gender *MaleFemaleHeight *Weight *Medical DetailsWe need to know a bit about you and your condition(s). Its important to give us as much detail as possible.Do you have any known allergies? *YesNoAre you currently taking any medication? *YesNoDo you have any medical conditions (e.g. liver, kidney, respiratory)? *YesNoHave you had any recent surgery or hospital admissions? *YesNoAbout This TreatmentHave you used this medication before?YesNoWas the treatment affective?YesNoDo you agree to take this medication exactly as prescribed and not exceed the recommended dose?YesNoWhat condition are you requesting this medication for?Safety and ConsentDo you understand the potential side effects (e.g. drowsiness, constipation, risk of dependency)?YesNo Please condition you Do you agree to use this medication as prescribed and not exceed the recommended dose?YesNoIs there anything else you would like to tell us before we review your consultation?Medication SafetyWhat type of pain are you suffering from? *How long have you been experiencing this pain? *Less than 1 week1–4 weeks1–3 monthsOver 3 monthsIs the pain associated with an injury or recent surgery? *YesNoHave you tried any other treatments for your pain? *YesNoDo you have a history of drug or alcohol dependency? *YesNoHave you ever been advised not to take opioid medications? *YesNoI understand this medication is a private prescription and not funded by the NHS. *YesNoI confirm that I am requesting this medication for myself and have answered all questions truthfully. *YesNoDeclarationPlease confirm *I confirm I have answered truthfullyAnd you consent *I consent to prescriber reviewing my answersThat you understand *I understand this medication is a private prescription and not NHS-fundedSubmit
