Patient Profile 
Important:  If you see that a patient profile is required for a certain product
 - You will need to complete this form so that we can  legally supply you with your requested medications.

Your Name
Name:

Surname:

Email:
Do you have any of the following drug allergies?
Please tick the appropriate box(es) below:
No drug allergies Aspirin
Codeine Erthromycin
Penicillin Sulpha
Tetracycline  
Other drug allergies
Do you have any of the following medical conditions?
No Chronic Conditions Arthritis
Asthma Diabetes
Epilepsy Thyroid
Stomach Ulcers High Blood Pressure
Glaucoma Heart Condition
Other medical conditions
 Prescribed Medicines
Not regularly taking any prescribed medicines - or -
Regularly taking medicine(s) that have been prescribed by a doctor or dentist.
The names of these medicines.
 
 Non Prescription & Other Medicines
Not regularly taking any non-prescription medicines - or -
Regularly taking medicine(s) obtained without prescription (Including from a pharmacy, supermarket, health food shop etc) eg. for headache, heartburn, etc. (including herbal and complementary medicines.)
The names of these medicines
Privacy:  We protect your information against unauthorized access or release. Your information is only accessible by the Pharmacy who processes your prescription.  We will not give, sell, rent, or loan any identifiable personal information to any third party, unless you have authorized us to or we are legally required to do so.  OnLine Pharmacy does not record your medication profile - This form along with your prescription is given directly to one of our member Pharmacies for dispensing.