Co–Codamol Tablets Consultation
Please fill in the questionnaire below. Any information provided will be kept confidential and will only be seen by a prescriber. These questions are designed to give our prescriber enough information to make a decision on whether the treatment is suitable, please fill them in truthfully.

The final decision to prescribe any medication lies with the prescriber. If they decide treatment is not suitable for you, the pending charge placed against your account will be cancelled and you will recieve a full refund.
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Email *
It is not recommended that you buy this medicine to share with other people as each person needs to be assessed individually by our pharmacy team.
Your Name *
Is this medicine just for yourself?
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 Please enter your date of birth:
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How would you describe the severity of the pain?
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What is the suspected cause of the pain? (eg. migraine, injury, medical etc.)
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Is this a long-term or short-term condition?
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Have you discussed the cause of your pain with your doctor? If so, give details. 
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Do you take any other medications? If so, give details. 
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Do you have any allergies to any medicines or other substances such as peanuts or soya? If so, please specify.
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Please agree that you:
Agree to our terms and conditions.

- You will read the patient information leaflet provided with your medicationYou acknowledge it is best to inform your GP of any medication you are prescribed.

-Confirm that you have capacity to consent

- Confirm you have answered the questions truthfully and accept any incorrect information given could be dangerous to your health.
I agree *
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