Treatment Questions – Your Chemists

Our doctors would now like to check your suitability for this product

Are you over 18?

Yes No

Are you pregnant, breast feeding or planning pregnancy,

Yes No

Have you ever had an allergic reaction to a vitamin supplement?

Yes No

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes No

Vitamin