Start your personalised request — pharmacist assessment

About you

We use this to contact you and to record an identified patient.

Full name *

Date of birth *

Sex *

Email *

Phone *

Postal address *

Patient weight (kg, optional)

Who is making this request? *

Your request

What kind of support are you looking for?

Preferred dosage form *

Describe what you’re looking for

Why are you requesting this? *

Why are commercial products unsuitable for you? *

Health screening

Please answer honestly. If unsure, choose “Unsure”.

Medicines and medical history

Helps the pharmacist check for interactions.

Current medicines

Current supplements

Allergies

Other medical conditions

If you have had any reaction (good or bad) to a previously compounded medicine, please describe (optional)

Specific interactions to check

Important for safe pharmacist supply.

Consent

Please read and confirm each item.

I confirm the information I provided is accurate.I understand the pharmacist may decide not to compound or supply the requested product.I understand the pharmacist may recommend a suitable commercial product instead.I understand that, if supplied, the product may be compounded by a pharmacist and is not assessed by the TGA in the same way as a commercially approved medicine.I understand I am free to use any pharmacy of my choice.I consent to the collection and use of my health information for pharmacist assessment, dispensing, compounding, counselling, follow-up and record keeping.