Medical Assessment

Are you requesting an EpiPen on behalf of a child?

Yes No

Please state your relationship to the child.

What is the child's age:

What is the child's weight:

What is the childs height

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

What allergies do you suffer from? (you may select more than one)

Allergy to insect bites or stings
Allergy to shellfish, soy or nuts
Other food allergy
Other (Please specify what allergie(s) you suffer from)

We are unable to prescribe you this medication.

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?

Never before
Less than one year ago
Between 1-5 years ago
More than 5 years ago

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you ever been advised by your doctor or specialist to carry an Epipen with you in the event of anaphylaxis?

Yes No

Why do you think you might need to carry an EpiPen?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you ever had to use an Epipen due to an episode of anaphylaxis?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you received training and are confident in using this Epipen if an episode of anaphylaxis occurred?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you confident that you would recognise the signs/symptoms of anaphylaxis?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

you answered truthfully to all the questions and you are aware that any incorrect information you provided might present a danger to your health;
the treatment is solely for your own use ;
you will read the patient information leaflet supplied with your medication;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Please tick the boxes to confirm the following:

I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

You must accept the terms and conditions to continue!