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Personal Consultation Form

Thank you for choosing ScripTrip. This form helps us understand your travel plans, health needs, and suitability for any recommended medications or kits.

Please complete all relevant sections carefully. Your responses will be reviewed by our pharmacist to ensure safe, appropriate recommendations.

All information is kept confidential and processed securely in line with GDPR and data protection standards.

Today's Date:

First Name (As It Appears On Your Passport

Last Name (As It Appears On Your Passport)

Your sex

Your sex
A

Your weight

Are you pregnant or trying to become pregnant

Are you pregnant or trying to become pregnant
A
B
C

Are you currently breastfeeding

Are you currently breastfeeding
A
B
B
C

Where are you travelling?

Dates of your travel: