Consultation Form – carewellpharmacy.co.uk

Date of Birth

Are you currently running with ourl consultation?

Yes

No

Have you noticed any specific triggers, such as food, pollen, dust, or pets?

Yes

No

Do you have a history of allergies or asthma, or does anyone in your family have them?

This is the description of my query.

Yes

No

Why are you want to check this treatment

Because You are great

I am ok you also

Not interest with you can manage

What is your weight and height?

Value must be between 100cm and 220cm

Switch to ft, in

What is you weight?

Please enter your weight in any combination of stones and lbs, lbs or in kilograms. e.g. someone who is 15st 6lbs could be entered as 15st 6lbs OR 216lbs OR 97.9kg.

Value must be between 40kg and 250kg

Switch to st, lb

Write some story about you?

What is your total experience ?

closing questions one

closing question two

would you like to add doctors detail

Yes

No

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Women's Health Consultation

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