Synergy Clinic - Prescribed Medication Pass Request Form

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Synergy Clinic Helpful Tip

More Synergy Clinic Helpful tips to come soon, watch this space for great health hints.

To gain access to the practitioner prescribed products, you need to fill in the following form as accurately as possible.

Surname:
First Name :
Address:
Postcode:
Contact Phone:
Email:
Date of birth:
Age:
Sex:
Occupation:
Marital Status:
Number of Children:
I have attended Synergy for a health appraisal?	Yes No
How would you like Synergy Clinic to help you? (Current symptoms)?
Are you pregnant?	Yes No
Females, last date of menstruation:
Are you breastfeeding?	Yes No
Please list all past surgery in detail (with dates, outcome):
Chronic Illness:
Allergies:
Were you breast fed?	Yes No Unsure
If yes, how long?
Current Medications (include prescription, contraceptives and natural medicines). Please list Medication Brand Name, Product Name, Dosage(tabs per day) and Date Commenced:
Have you or anyone in your family had any of the following? (tick box for yes):	Allergies/Hayfever Alcoholism Alzeimer's Arthritis Asthma Cancer - Bowel Cancer - Breast Caner - Liver Cancer - Lung Cancer - Prostate Other Cancer Diabetes Epilepsy Heart Disease High Blood Pressure High Colesterol Infertility Low BLood Pressure Menstrual/Menopausal Problems Mental Conditions Obesity Sinus Skin Complaints Thyroid Conditions Other, please specify
INDEMNITY POLICY Synergy Clinic . Com agrees to grant access to prescribed products online for the use of myself only. I understand that I am only allowed to purchase prescribed products for my own use and that I am not permitted to share my password access with others. Synergy Clinic . Com may verify this information before processing orders for prescribed products. Synergy Clinic . Com practitioners have the authority to deny access to any product they deem unhelpful or potentially harmful to my condition. I understand that it is my responsibility to notify Synergy Clinic . Com in writing of any changes to my medication schedule (including natural products) and of any changes in my health (immunisations, surgery, injuries, new medical conditions diagnosed, pregnancy etc). Furthermore I agree to abide by the recommended dosages and will indemnify Synergy Clinic .Com against any damage or loss suffered as a result of my own negligence to disclose all relevant health information, store medications safely + abide by labelled dosages and rules of the site.
Do you agree to the above indemnity policy?	Yes No
I AM ABOVE 18 YEARS OF AGE AND ALL OF THE ABOVE INFORMATION IS TRUE + CORRECT + I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM SYNERGY CLINIC . COM OF ANY CHANGES TO THIS.
Do you agree to the above statement?	Yes No