Hayfever medication request form

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You can use this form to request for medications or treatment related to your hayfever

** Please allow 2 working days for the form information to be processed by the surgery

If medications are issued they will be sent to your nominated pharmacist automatically unless you specify otherwise. If you do not have a nominated pharmacist please nominate one or the surgery will send to the nearest one to your current abode

Information regarding hayfever

Read: https://patient.info/allergies-blood-immune/hay-fever-leaflet
Watch: https://www.youtube.com/watch?v=xNteA7X7ho4

YOUR DETAILS

Please include your latest personal details so that we can contact you if necessary

Your Full Name *

Your Date of Birth *

Please include your DOB in the form of DD/MM/YYYY i.e 01/01/1980

YYYY

Your MOBILE number *

If we need to contact you to clarify your answers

Your EMAIL number *

If we need to contact you to clarify your answers

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