Name: Davidsons Chemists
Telephone: 01250 872308

Remote Consultation Request

Please fill in this form and it will be emailed to your chosen pharmacy. The pharmacist will contact you as soon as they can

Name*
Prefix First Name Surname
Date of Birth*

Day
Month
Year
Sex at Birth*
- Male
- Female
Address*
Street Address Address Line 2 City Postcode
'If you are requesting a consultation for a person under the age of 16, please only do so if you are a parent or guardian'
- Parent
- Guardian
- Other - please state relationship below?
If you are requesting a consultation for a person under the age of 16, please only do so if you are a parent or guardian
Please give relationship to patient
Parent or guardian name
Prefix First Last
Phone Number*
Local Davidsons Pharmacy*
What would you like to be seen about?*
Tell us briefly about your symptoms or the condition you'd like a consultation on: We will contact you initially by phone, so please provide telephone number: If appropriate, we may offer a follow-up via video consultation.
Consent to view my clinical information.*
- Yes, I agree to the pharmacist accessing my clinical information.
- No
I agree to the pharmacist accessing my clinical information. I consent for the consulting pharmacist to view my clinical information prior to, or during the consultation. They may access your pharmacy held patient information record and/or access your NHS held Emergency Care Summary (ECS). The ECS is a list of medicines prescribed by your GP practice. It does not contain information about medicines that have not been prescribed by your GP e.g. chemotherapy, clozapine, memory drugs, over the counter and herbal medicines so we will ask about any additional medicines.
Consent to contact your GP practice*
- Yes
- No
We work in close contact with GP practices to provide you with the best care possible. We will contact your GP practice if a prescription only medication has been supplied as a result of your consultation. If you do not wish your GP practice to be contacted, this may limit what can be issued to you. Please tick here if you DO NOT wish your GP practice to be contacted with the outcome.
Email
This field is for validation purposes and should be left unchanged.