Allergic Rhinitis (2 years & over) and Allergic Conjunctivitis (2 years & over)

Name

Address

Eircode

Contact Number

Scheme Number

GMSGP VisitDPSPrivate

Name of Parent/Guardian (if patient under 16 years)

Date of Birth

Is this appointment for a child under 2 years of age?
YesNo

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please make an appointment with your GP or relevant medical practitioner.

Are you pregnant, or suspected pregnant?
YesNo

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please make an appointment with your GP or relevant medical practitioner.

Are you suffering from any of the below symptoms?

Persistent headache, eye or facial pain

Nasal symptoms present primarily in only one nostril

Blurred vision

None of the above

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please make an appointment with your GP or relevant medical practitioner.

GP Details*

Name

Address

Contact Number

*Not mandatory

Select store for consultation

Consent

Do you consent for the pharmacist on duty to review the information you provided above and if you are deemed a suitable candidate, for them to contact you to organise a suitable time for the consultation.

Allergic Rhinitis (2 years & over) and Allergic Conjunctivitis (2 years & over)