Questionnaire for Repeat Prescription

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All (*) marked questions are mendatory

I confirm I am 18 years old or over *

YesNo

For safety reasons We DONOT prescribe any of the following medications *

Painkillers of any type
Sedatives / sleeping aids including benzodiazepines such as Diazepam (Valium) and Zopiclone. Catapres or clonidine
Any smoking cessation medication like Zyban and Champix
Steroids of any kind for any purpose
Weight-loss medications oral or injectables
Antibiotics for any acute infection no matter how minor or even as continuation therapy
Certain other medications, at the doctor's discretion

If you have still asked for one of these meds the doctor will not call you and will simply refuse the consult. Do you understand this advice?

YesNo

Please write names of your usual medications with doses *

Do you have any drug allergies *

I confirm that I have entered the information correctly. *

I confirm that the medications entered were started by my own regular GP and therefore Panraa Clinics takes no responsibility of errors of treatment or monitoring of side effects of these medications. In additions Panraa Clinics takes no liability for loss or damage arising from services or medications prescribed if I have supplied incorrect or incomplete information.

Do you understand this statement?

YesNo

I confirm that *

I take responsibility for informing my GP of this consultation and any subsequent health issues
I understand Panraa Clinics is not liable for damages which arise from my failure to inform my GP or other healthcare professional about treatment I receive from the website
I understand the limitations of an online consultation
I am aware that Panraa Clinics is only providing me scripts of medications and in no way is replacing my regular GP. If I have any concerns about any aspect of my health I will consult with my regular GP
I agree to the website privacy policy and terms and conditions

YesNo

Consents *

I confirm that I understand the limitations of an online consultation
I confirm that I am aware that this may not replace the need for a face to face consultation and examination with my GP
I confirm that if I have any concerns about any aspect of my health I will consult with my regular GP
I confirm that I take responsibility for informing my GP of this consultation and any subsequent health issues
I confirm that I understand Panraa Clinics is not liable for damages which arise from my failure to inform my GP or other healthcare professional about treatment I receive from the website
I confirm that I agree to the website privacy policy and terms and conditions
I confirm that I have read the refund policy in the FAQs section and I agree to this policy

I agree with all consents