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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.

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

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