Start your personalised request — pharmacist assessment

Step 1 of 5: About you20%

About you

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

Full name *

Date of birth *

Gender *

Email *

Phone *

Postal address *

Patient weight (kg, optional)

Who is making this request? *

How would you prefer we contact you if the pharmacist has a question?

Your request

What kind of support are you looking for?

Preferred dosage form *

Describe what you’re looking for

What is this for? Tell us the symptom or goal in your own words. *

Have you tried a ready-made (shop or pharmacy) product? What was the problem with it? *

By law we can only compound when no suitable commercially available product exists, so this helps the pharmacist assess your request.

Your health

A few questions that matter for any preparation. If unsure, choose “Unsure”.

Are you pregnant, planning pregnancy, or breastfeeding?

Yes

Unsure

Do you have kidney disease or reduced kidney function?

Yes

Unsure

Do you have liver disease?

Yes

Unsure

Do you have heart disease or high blood pressure being treated?

Yes

Unsure

Any difficulty swallowing tablets or capsules?

Dietary or religious requirements (optional)

Medicines and medical history

Helps the pharmacist check for interactions.

Current medicines

Current supplements

Allergies or intolerances — medicines AND ingredients

Other medical conditions

Have you used a compounded medicine or supplement before?

Yes

Unsure

Is this a continuation of a previous formulation you've had compounded?

Yes

Unsure

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

Anything else the pharmacist should know? (optional)

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, as described in the CustomDose Privacy Policy (customdose.com.au/privacy).