Integrative Medicine Consultation – Dickson Chemist

Thank you for booking your integrative medical consultation. In order to proceed, we need you to fill in the consent and medical information form below. Once you have completed this form, your consultation will be formally booked – until we have this form completed your allocated time and date is held – but is not presented to a prescriber. This is an essential part of the process which cannot be skipped, and must be completed at least 2 working days before the consultation date and time.

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 *

Which condition are you wanting looking to have therapy for??

Best phone number to get you on *

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 am not currently pregnant, and will take (if appropriate) precautions against this during therapy. *

Tick here

Agree to the following statement: Off license prescribing is a private service. £80 is the cost of an initial consultation and will include (if appropriate) a physical prescription for up to 3 months supply. This does not include the cost of the actual medicine which must be paid separately. After the first 3 month prescription is finished, OR at a mutually agreed interval, I will need a review with my prescriber – and I am aware there is a further cost to this of £30 – in order to continue with this medication. Reviews thereafter will be 3 / 6 / 12 months as appropriate and will incur review fees on each occasion. *

Tick here

I formally consent for Dickson Chemist to act on my behalf, to arrange a consultation. I have completed research on the therapies I am requesting and understand what I am asking for is an unlicensed medicine and as such, formally disclaim all prescribers and dispensers from any or all harm caused. If appropriate 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 * Scan of photographic ID * Any evidence of medications taken (i.e. a repeat form) *

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 *