Registration Before you can purchase any medication you must complete the following simple questionnaire. Bold questions must be answered. 1. Personal details First name* Surname* Date of Birth* Title Username* Password* Ethnicity Address* Post Code* Home Tel No Mobile Tel No* Email Adderess* NHS Number Occupation Emergency Contact Please state Relationship Tel No Address 2. Allergies Do you have any drug allergies or other allergies? * Yes No Details Details and nature of the reaction: Please List Here 3. Present Illnesses, (Please Tick) Asthma COPD Cancer Epilepsy Diabetes Stroke Heart Disease Thyroid Disease Any Ongoing Investigations Hospital or by GP/Doctor Any other Illnesses Please complete any other Significant Past or Present Medical history and if possible please provide the approx. date. Please List Here your Current Medications and Significant Past Medications Do you have any communication/information needs relating to disability, impairment or sensory loss, if so what are they: (e.g. Deafness, Blindness etc): Please List Here Please advise us of any family history of illnesses or do you wish to tell us any other medical information: Please Tick the Box to state that the details you have entered on this form are correct and you consent for this information to be entered on your medication records with Medic plus Clinic. Contact us: Email: firstname.lastname@example.org Tel: 02089974446 *I agree to the Terms and Conditions × Thank you for completing this form. If you would like a health check, please ask for an appointment at reception.