Thank you for booking your consultation for Veoza. Below, please find a medical consent form – which you will need to fill in once you have received and completed your liver test. This will come special delivery to you by post – just follow the instructions and take a photograph to upload here at the bottom along with some ID and diagnosis information. 

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Name *

First

Last

Address: *

Date of birth – please note you must be over 18 for this therapy *

Email *

Best phone number to get you on *

Who is your primary care physician (GP) as this medicine is a new medicine we must, by law, inform your NHS doctor. Please provide name and address. *

I am not currently pregnant, currently taking HRT or hormone therapy containing estradiol (or will stop before starting Veoza), *

• Tick here

I understand I have paid £100 for the medical consultation, this does not cover the cost of the actual medicine Veoza which will be charged after the consultation and the generation of a prescription by the prescriber. This is reviewed every 3 months thereafter and charges for formal review may apply. *

• Tick here

I formally consent for Dickson Chemist to act on my behalf, to arrange a consultation for Veoza. I have completed research on this product I authorise Dickson Chemist to take over managing my repeat prescriptions and working with my prescriber directly. I understand that this a PRIVATE non-NHS service which will attract cost for prescribing and dispensing. I confirm that I am not pregnant or breastfeeding and will take adequate precautions during my therapy period. I will upload the following items below: * Scan of paperwork showing my diagnosis (if possible)* Scan of photographic ID * Any evidence of medications taken (i.e. a repeat form) and the photograph of the liver function test sent to me by post. *

• Agree

Medical evidence upload. 1) Evidence of diagnosis (if available) 2) Photographic ID or selfie holding a household bill 3) Evidence of any medications you take (such as a repeat form) 4) Photograph of liver function test (that we send you by post) completed *

Click or drag files to this area to upload. You can upload up to 5 files.

Additional Comments / Tell us a little bit about yourself and your pertinent medical history *

Submit