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Disclaimer - Ear Infections Consultation

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.
 

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?
What is your Date of Birth?
Day
Month
Year

If Yes Give Details

If Yes Give Details

If Yes Give Details

If Yes Give Details


Are you pregnant or breast feeding?

If Yes Give Details

Please select all the symptoms that apply:
Have you ever suffered from the following: Please select all that apply:

If Yes Give Details

Do you understand this medication is not for prolonged use?
Please confirm the below; I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to infor
Product
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