Required
Required
Required
Required

Measurements

Has the child received any medical diagnoses? Required
Is the child taking any medications currently, either prescribed or over-the-counter? Required
Does the child have an allergy to any medication? Required
Can the child swallow tablets and capsules? Required
Do you have family members with a history of early heart disease including a pacemaker or heart problems below the age of 40? Required

Please confirm that you have watched the two videos before submitting this form

Required

This information can be obtained from your GP or local pharmacy. If you are unable to get these done, please contact us so we can offer an appointment to do this in clinic, however this may cause a delay.

After we receive this information, your allocated prescriber will make contact. They will only make contact once these have been emailed in. We may want to do further investigations but we will let you know if that’s the case.