Name*

Prefix First Last

Date of Birth*

Age of patient*

Gender*

Male
Female
Other

CHI - If known

'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

Address*

Street Address Address Line 2 City Postcode

Preferred Contact Method*

Telephone Consultation
Video Consultation

Email*

Please enter your email address so that we can send connection instructions.

Phone*

Mobile Number*

Fully encrypted video consultations from Europe’s largest digital healthcare provider. No need to download any software. We will send you a weblink direct to your smartphone. If your connection is lost you will need to request a new link. Find a quiet and private place to sit. Please make sure that your mobile phone is charged and has a good internet connection.

Preferred contact time-slot

We will try to contact you as close to this time as possible.

Local Davidsons Branch*

Please note that you may be contacted by a different pharmacist supporting your local branch from another location

Please can you provide information that you think will aid our Pharmacist with your 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.

Remote Consultation Request