Private Prescription: Date:
Practitioner details: Email: Tel:
Patient details: D.O.B:
Address: Email: Tel:
Please describe the treatment that your products are going to be used for:
- Is your patient pregnant or breast feeding?
- Does your patient have a history of severe allergy/anaphylaxis, ?
- Is your patient currently receiving any medical treatment? .If yes, details:
- Has your patient previously received any aesthetic treatments, ? .If yes, detail:
- Does your patient suffer from any scalp issues? i.e. Scalp Psoriasis/Eczema, Scalp Herpes, Scalp Dermatitis or Scalp infection . If yes, details:
Prescription item (s) : Pharmacy Ref.
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X
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Prescriber details:
Patient consultation date:
By signing this prescription, you confirm that you are aware of and accept clinical responsibility for all items prescribed for your patient. You also confirm that a face to face consultation has taken place or available/ offered to patient. If you have any questions, please call 02073239798 or email: [email protected]
