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Hay Fever Treatment

Only €23 per Script

Hay Fever Prescription

First Name

Last Name

Date Of Birth

Email

Phone Number

Address

Please specify your gender: *

Male

Female

Please provide the names of the medicines, their dosage, and times to take them per day.

Please upload a photo of your current medicines. (Optional)

Upload File

Upload supported file (Max 15MB)

Please upload your previous prescription if available. (Optional)

Upload File

Upload supported file (Max 15MB)

Is your condition well-controlled by your current medicines? *

Yes

No

If No, Please specify:

Do you plan to become pregnant, breastfeed, or are you pregnant? (For Females) *

No

Yes

If Yes, Please specify:

Do you have a significant past medical or surgical history? *

No

Yes

If Yes, Please specify:

Are you allergic to any medication or any other substance? *

No

Yes

If Yes, Please specify:

Please provide the name and address of the pharmacy where you'd like to pick up your medications.

I confirm that the answers I have provided for the above questions are true and accurate to the best of my knowledge. *

I Confirm

I Do Not Confirm

I confirm and agree that any treatment prescribed for me is for my personal use only. *

I Confirm

I Do Not Confirm

I fully understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request. *

I Confirm

I Do Not Confirm

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