Please use the form above to send us the medical information we need in order to sell you a Pharmacy Only Medicine by filling in your details and pressing the 'Send' button.
Why do I need to fill in this form?
It is a legal requirement that Pharmacy Medicines are sold under the supervision of a pharmacist, who must ensure that the medicine is being used properly. The questions that we ask will give us the background we need to determine this, so please answer them fully because the pharmacist will not authorise the sale until he is happy with the details. It is important to check the box confirming that you have read the information that we give on our web site to confirm that you are using the medicine accoring to the guidance given.
What do you do with the answers on the form?
We store all this information on a secure database, and you will not need to send it again if you order the same product in the future, however we do need new information if you are using a new product, or if your details have changed. We are registered for the storage of this data under the Data Protection Act, and can not delete it.
Do I need to send a separate form for every medicine?
It is not necessary to use a different form for every medicine you are ordering, so you can list all the medicines you are ordering on the one form.
What do I do if I can't get the form to work?
If the form doesn't give you the message at the top saying 'Hi! Your details have been sent and saved' after you press the 'Send' button at the bottom, then you can answer the following questions by e-mail. Copy and paste them into your e-mail, answer them and send them to orders@mypharmacy.co.uk
Your name -
Your e-mail address -
Country the medicines are being sent to -
Name of the person using the medicines -
How old is this person? -
Other medicines or supplements taken? -
Other medical conditions they have -
Which medicines do you want to buy? -
Have you read the product information page? -
What are the medicines being used for? -
Why are you ordering more than one of any medicine? -