LDN Research Trust – Rapid Consultation – Dickson Chemist

You have been redirected to this page in order to complete your consent form, and upload your medical information for your consultation or transfer from another clinic.

Please answer all questions and make sure you submit this form at least 24h before your consultation, or within 8 weeks if transferring from another clinic. Please note this service is only available for over 18s. If you require a referral to a pediatrician please call us.

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.

Which condition are you wanting to try LDN 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 wth LDN. (NOTE: Our prescribers are not insured to prescribe to assist with fertility problems.)

Tick here

Agree to the following statement: LDN prescribing is a private service. £50 is the cost of an initial consultation and will include (if appropriate) a pysical prescription for 3 months supply. This does not include the cost of the actual medicine which must be paid seperately. After the first 3 month prescription is finished, 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 for LDN. I have completed research on www.ldnresearchtrust.org or similar materials 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