Allergies/Hay Fever Updates Details RequiredPatient InfoPayment DateTimeFirst NameLast NameWhatsApp NumberEmailID NumberDate Of BirthHave you used our services before? 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Itchy eyes Sneezing Runny or congested nose Post-nasal drip Itchy skin Itchy nose, mouth, throat or ears OtherWhat allergy symptoms do you usually experience? (Other)Are you currently sick and think you need a prescription for treatment including antibiotics? Yes No⛔ 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 ⛔⛔ 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.Are you currently pregnant or breastfeeding? Pregnant ⛔ Breastfeeding ⛔ No Not applicable⛔ 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.Do you have any other medical conditions? Yes NoIf yes: What medical conditions do you have?Are you currently taking any other medication? Yes NoIf yes: What medication are you taking?Do you have any allergies to medication? Yes NoIf yes: What allergies do you have?PreviousNext 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.Please note that ID verification is required for all patients I Agree to the terms and conditions of this Prescription Application and that of the use of this service.PrescriptionPrice: R250.00Coupon CodeApply CouponNo payment items has been selected yetIf you require an invoice for medical aid, please fill out the belowMedical Scheme (Medical aid name)Membership NumberDependent CodeICD 10 Code (DO NOT EDIT)Submitting this clinical form with any “⛔ (do not proceed)” conditions will disqualify you from receiving a prescription. Previous Submit And Pay
