P-line Request - Prime Response Pharmacy, London

Pharmacy-Only Medicine Purchase Request Form

At Prime Response Pharmacy London, your health and safety are our priority. Please fill out this form before purchasing Pharmacy-Only (P-Line) medicines. This information helps us ensure that the medicine is suitable for you.Pharmacy medicines are sold at the professional discretion of our pharmacists. Please answer the following questions accurately to allow our pharmacy team to check that this product is suitable for the intended patient(s). All information will be treated confidentially and will only be available to the pharmacy staff processing your order.

The pharmacy team may need to contact you by phone for additional information. Please ensure that the contact details you provide when you check out are correct. If your previous responses are shown below, please check that your answers are still accurate.

Please note, the pharmacy team reviewing this order only have access to the details on this form. They don’t have access to any other patient information that may have been provided either in store or online on previous occasions.

Pharmacy-Only Medicine Purchase Request Form

Full Name:

Date of Birth:

Contact Number:

Email Address:

Name of the medicine you are requesting:

Dosage/Strength (if applicable):

How long have you been taking this medicine (if applicable)?

Are you purchasing this medicine for yourself or someone else?

Are you currently taking any other medication, including herbal or over-the-counter medicines?

If yes, please list them:

Do you have any known allergies?

If yes, please list them:

Are you pregnant, planning to become pregnant, or breastfeeding?

Do you have any existing medical conditions? (e.g., diabetes, asthma, high blood pressure, etc.)

If yes, please provide details:

Have you had any recent or ongoing health concerns or symptoms? (e.g., pain, infection, rash, etc.)

If yes, please describe:

Why are you requesting this medicine today? (e.g., symptoms, diagnosis, etc.)

Have you used this medicine before?

If yes, was it effective and did you experience any side effects?

How long do you intend to use this medicine?

Do you have any concerns or questions about taking this medicine?

I confirm that the information provided is accurate and complete to the best of my knowledge.

I understand that Pharmacy-Only medicines must be used as directed, and I will follow the instructions provided.

I consent to the pharmacist reviewing this information and contacting me if further clarification is required.

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At Prime Response Pharmacy, we are committed to protecting your privacy. Your personal information will only be used to process your request in accordance with data protection regulations. By submitting this form, you agree to our terms and conditions.

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