Design Your Product

Medicine Request Form

1. Please specify the condition you are wanting to treat:

2. What caused the condition?

3. How long have you had the condition for?

4. Have you tried a compounded product before?

Yes

5. If Yes, can you outline or describe what formulation you have used?

6. What products or medications have you used in the past that have worked?

7. If you answered above, why is the option above no longer an option or not working?

8. What products or medications (prescribed or not) have you tried which did NOT work?

9. What other therapies have you tried relevant for your condition?

10. Do you have any allergies or intolerances to certain ingredients?

11. Are there any specific features or benefits which you would like this compounded product to have?

12. What is your main reason for seeking a compounded alternative?

13. To assess the suitability of your compounded formulation, what other Medications are you currently taking for any other medical conditions?

14. In what way would you like to receive your dose?

For oral formulations, what are some preferred flavour options? Suggest 3

Suggestion 1

Suggestion 2

Suggestion 3

15. Please enter PATIENT personal details

Sex

Male

Female

First Name

Surname

Date of Birth

Address Line 1

Suburb

State

Post Code

Telephone (landline preferred)

Email address

Fax

16. Are you the patient listed above

Yes

If NO, please complete your full name below and your relationship to the patient

Medical Conditions