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Book an appointment with The Pharmacist
Whether your taking medicines from your doctor or just want to make sure you're as healthy as you can be, we're here to help.
You can book an appointment with one of our professional healthcare team and we can make an assessment of your needs, and offer advice on keep you in the best health possible.
If you'd like to book in for a consultation about your medicines or general health issue please fill in this form and we'll be in touch.
All information provided on this form will be kept in the strictest confidence.
Name
*
Prefix
First
Last
Please enter your name
Email
*
Confirm
Contact Phone Number
*
Can we contact you at this number if we need to?
Yes
No
Tick the box
Which day would suit you?
*
DD
/
MM
/
YY
What Time?
HH
:
MM
AM
PM
AM/PM
Would you prefer to talk to a male or female Pharmacist?
*
Male
Female
Not worried
Additional Requests
E.g Saturday or out of hours appointments.
Consent to Pharmacist accessing my medical information
*
Please allow Pharmacist from CookStPharmacy to access medical information held in eclair system
To allow us to access lab tests and other health information please tick
Total
$30.00
