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P MEDS PRESCREENING

Please fill out the following form - your request for the medication of your choosing will be reviewed and our Pharmacists will be in touch upon review.

Which medication are you enquiring about?*

First name*

Last name*

Email*

Date of birth*

Day

Month

Year

Address*

Email*

Phone*

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

Do you have any allergies?*

Are you currently taking any medication?*

Please provide a form of ID (passport, driving license or birth certificate)*

I declare that the info I’ve provided is accurate and complete.

CENTRA PHARMACY

info@centra-pharmacy.com

ROUTE1 PHARMA LIMITED, registered as a limited company in England and Wales *(or Scotland) under company number: 12403147.

Registration number:1029132 | Punita Joshi and Imran Razaq

Registered Company Address: 20 Queens Square, High Wycombe, Buckinghamshire, England, HP11 2DF.

Concerns or feedback

should first be directed to the Superintendent Pharmacist. If further escalation is needed, you can contact the General Pharmaceutical Council (GPhC) or NHS England, depending on the nature of the issue.

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