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Gender:
Date of birth
Is this medication for your personal use?
Can you please provide more details?
For further information kindly contact our patient support team:
0207 867 3932
email help@clickpharmacy.co.uk.
What symptoms are you suffering from? Please tick all the symptoms that apply to you.
Do you suffer from any of the following?
Are you allergic to chloramphenicol or to any other medicines?
Are you taking any other medication (including prescription, over the counter or herbal medication)?
Are you pregnant or breastfeeding or planning to get pregnant or start breastfeeding?
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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