Patient Agreement (Prescription Medication)


  • I have had a recent appointment with my own doctor.
  • I have been fully informed and understand the risks, benefits and any possible side effects of the medicines that I request.
  • I require the particular medicines solely for my personal use and I agree not to give, sell or pass them to any other person.
  • Should any complications or side effects develop I agree to immediately contact a doctor for advice or assistance.
  • I confirm that I have answered all questions truthfully and to the best of my knowledge.
  • I understand that if I supply incorrect information it could lead to inappropriate advice being given to me or the wrong medicine being prescribed, which could be harmful to my health.
  • I will inform my own doctor about the medicines I received.