Condition Form

Name*

First

Last

(ONLY if booking for someone else) Provide their name and yours on top otherwise leave blank

First

Last

Phone*

Email*

Email confirmation*

Date of Birth*

day

/

month

/

year

Address*

Street Address City Province Postal / Zip Code Country

Please Enter Your Health Card Number*

Conditions*

Acne: Clogged pores cause pimples, blackheads, and cysts.

Allergic Rhinitis: Allergy-triggered sneezing, itching, and runny nose.

Canker Sores: Painful, non-contagious mouth sores.

Oral Thrush: Mouth infection with white patches and soreness.

Pink Eye: Eye redness and itching from infection or allergy.

Eczema: Red, itchy skin from allergies or irritants.

Diaper Rash: Skin irritation in the diaper area.

Dysmenorrhea: Painful menstrual cramps and bloating.

GERD: Acid reflux causing heartburn and discomfort.

Hemorrhoids: Swollen, painful rectal veins, often with itching or bleeding.

Cold Sores: Painful blisters around the mouth, contagious.

Impetigo: Red sores on the face that ooze and crust.

Insect Bites and Hives: Red, itchy bumps from bites or allergies.

Lyme Disease Prevention: Risk of Lyme disease from tick bites.

Musculoskeletal Sprains and Strains: Painful injury to muscles, tendons, or ligaments.

Nausea and Vomiting of Pregnancy: Morning sickness in early pregnancy.

Pinworms and Threadworms: Intestinal worms causing anal itching at night.

UTIs: Urinary infection causing pain, burning, and frequent urination.

Yeast Infection: Vaginal itching, soreness, and discharge.

Message (Optional)

Do you consent to be assessed by the pharmacist for the provision of minor ailments services*

Yes, I Consent.

Do you consent to the collection and use of your personal information in accordance with privacy regulations?*

Yes, I Consent.

Please review all fields in the form! then submit
Thank you