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Gender:
Date of birth
What allergies do you suffer from? (you may select more than one)
For further information kindly contact our patient support team:
0207 867 3932
email help@clickpharmacy.co.uk.
When did you first get prescribed an Epipen?
Have you ever been advised by your doctor or specialist to carry an Epipen with you in the event of anaphylaxis?
Why do you think you might need to carry an EpiPen?
Have you ever had to use an Epipen due to an episode of anaphylaxis?
Have you received training and are confident in using this Epipen if an episode of anaphylaxis occurred?
Are you confident that you would recognise the signs/symptoms of anaphylaxis?
Are you taking any other medication?
Please provide the name, dosage and the reason why you are taking that medication or medications.
Do you agree to the following?
Please tick the boxes to confirm the following:
Order before 15:00pm (Monday to Friday) for next day delivery
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