Allergies / Hay Fever Prescription - Online Prescriptions | Affordable, Quick, Easy

Date

Time

First Name

Last Name

Contact Number

ID Number

Date Of Birth

Have you used our services before?

Yes

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

What allergic condition do you have and when were you diagnosed with it?

What allergy symptoms do you usually experience?

Itchy eyes

Sneezing

Runny or congested nose

Post-nasal drip

Itchy skin

Itchy nose, mouth, throat or ears

Other

What allergy symptoms do you usually experience? (Other)

Are you currently sick and think you need a prescription for treatment including antibiotics?

Yes

⛔ Please Do not proceed, this condition will disqualify you from receiving a prescription.
Please click here to WhatsApp our On Call Doctors for an instant consultation. The doctor will advise on a treatment route that will suit you personally.

What allergy medication/s are you requesting a repeat of? (include dose)

How often do you use each of your allergy medications?

Are you happy with your current allergy medication?

Yes

No ⛔

Are you currently pregnant or breastfeeding?

Pregnant ⛔

Breastfeeding ⛔

Not applicable

Do you have any other medical conditions?

Yes

If yes: What medical conditions do you have?

Are you currently taking any other medication?

Yes

If yes: What medication are you taking?

Do you have any allergies to medication?

Yes

If yes: What allergies do you have?

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service.

I understand the questions above and have answered honestly. I understand that any inaccurate or false information could potentially be dangerous to my health and safety.
The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.
I agree to the Terms & Conditions of this platform.
I am 18 years or older.
I am currently living in South Africa.

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

Prescription

Price: R250.00

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Medical Scheme (Medical aid name)

Membership Number

Dependent Code

ICD 10 Code (DO NOT EDIT)

Submitting this clinical form with any “⛔ (do not proceed)” conditions will disqualify you from receiving a prescription.