Thank you for booking your general medical consultation.

Patients use this consultation form to make a specific request for a medication or therapy privately. Often these are unlicensed medicines, being used off label for cancer or additional therapies for autoimmune disease not allowed on the NHS

You will need to have identity information, and medical history at the end – we will need some more information from you.

The more information you give us, the better the consultation is going to be for you. Please note, our prescribers are not able to prescribe controlled drugs.

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Name *

First

Last

Address: *

Date of birth - please note you must be over 18. Minors must have a face to face consultation with a registered doctor or pediatrician - call us on 0141 404 6545 option 1 for a referral. *

Email *

Best phone number to get you on *

Tell us the condition you want treated for and/or the medicine you wish to have prescribed (if you know)

Who is your primary care physician (GP) as we may need to talk to them about your request unless you opt out *

I will contact my GP myself, you do not have my permission to contact my primary care providers about my care.

• Tick here

I formally consent for Dickson Chemist to act on my behalf, to arrange a consultation. 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 if I am advised to do so. I will upload the following items below: * Scan of paperwork showing my diagnosis * Scan of photographic ID * Any evidence of medications taken (i.e. a repeat form). If the therapy I am prescribed is off-licensed/unlicensed, and at my specific request, I formally discalim all prescribers and dispensers for any harm howsoever caused. *

• Agree

Medical evidence upload. 1) Evidence of diagnosis 2) Photographic ID or selfie holding a household bill 3) Evidence of any medications you take (such as a repeat form) *

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