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5 Minute Consultation

If you are currently experiencing any symptoms for a minor ailment, please fill out the form below. You will receive a call from the pharmacist to assess your condition and direct you to the right service.

This is may be advice along with medication over the counter or a private prescribing consultation.

First name

Email

Phone

Last name

Date of Birth

Please select your gender:

Male

Female

Other

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Country

Please can you describe the symptoms you are experiencing.

How long have you been experiencing symptoms?

Please select if any of the following apply to you:

Pregnant

Breast feeding

Pregnant and Breast feeding

N/A

Do you suffer with any medical conditions? (if yes please state below)

Are you currently taking any medication? (if yes please state below)

Do you have any allergies or sensitivities? (if yes please state below)

Were you referred by another health care professional? Please tick below

GP Surgery

Another pharmacy

Dentitst

Other

How did you find out about us?

Patient at the pharmacy

GP surgery

NHS website

Google

Internet (other websites)

Leaflets

Facebook/ Instagram

Word of mouth

Other

Please upload any images that may help us to understand your condition.

Upload File

Upload supported file (Max 15MB)

I confirm all the information provided is accurate to the best of my knowledge.

Thanks for submitting!

GPhC Registration number: 1038758

©Epicare Health Ltd.

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