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Select 'Yes' if you give permission to share this information with or seek more information from your GP, we will hold your order until GP approval has been given. Not providing consent may limit the services provided by the prescriber.

Pregnant/breast feeding/intending to become pregnant?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please confirm that your GP or specialist consultant has diagnosed the condition for which you intend to take this medication and is happy for you take it?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please confirm that you will inform your GP that we have issued you with this medication

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you consent to us liaising with your GP should an issue arise?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Have you taken this medication before?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

If you have taken this medication before, did it cause you any problems

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you suffer with any other medical conditions for which you are currently taking medication?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are there any other symptoms or underlying medical conditions the prescribing doctor needs to be aware of?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are there any other medications (including both prescribed and self-purchased) you intend to take together with the ordered medication?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Any allergies, side effects or adverse reactions with any medications in the past?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Would you describe your health condition as excellent?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Would you describe your health condition as good?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Would you describe your health condition as poor?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of mental health problems?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of ongoing breathing problems (eg poorly controlled or moderate to severe Asthma/COPD)?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of Myasthenia Gravis?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of muscle weakness of the chest wall

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of severe Sleep Apnoea

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of Liver or Kidney Problems

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please confirm you don't take any of the following medications? Antiepileptic, Antipsychotic, Antifungal, Chemotherapy or related cancer drugs, Clarithromycin, Diltiazem, Dronedarone, Erythromycin, HIV medications, Netupitant, Rifampicin, Verapamil.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you intend to use this medication for mild/transient insomnia?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Zopiclone should only be for short-term use, up to 4weeks. Can you confirm you only intend to use it short-term?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you have any history of drug or alcohol dependence?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

This medication is potentially addictive with the risk of causing both physical and psychological dependence with regular use. Please confirm you understand and agree with this advice.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you believe that you may be addicted to this drug?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you believe you could stop taking this medication if you wanted to?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you obtaining this medication from any other source including your GP or other online sources?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please be aware that this medication can cause drowsiness which may impact on your ability to drive safely. We advise not to drive if you experience any symptoms or signs (such as experiencing sleepiness, poor coordination, impaired or slowed thinking, dizziness, or visual problems) suggesting that your driving may be impaired. Please confirm you understand and agree with this advice.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please confirm that you have read & understood that when we perform an identity check on your name, this will leave a footprint on your file that an ID check was done, this will not affect your credit rating.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please confirm that you have given us permission to use your personal information with a Credit Reference and Fraud Prevention Agencies to perform an identity check on you.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Please confirm that you have read & understood the terms and conditions that we use your personal information by ourselves and at Credit Reference and Fraud Prevention Agencies to perform an identity check.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you agree to read the patient leaflet before taking any medication prescribed to you?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you agree you must stop taking this medication and contact your GP or other urgent healthcare provider if you experience any adverse effects related to taking it. You should also liaise with your GP if you start any new medication or you develop a new medical condition during treatment which wasn't declared on this questionnaire?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Do you agree this medication will be solely for your own personal use?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

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