Patient - Application for Anthelmintic

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STEP 1 OF 1

What is your birth sex? *

Male

Female

Describe your symptoms as best you can: *

Are you currently or in the last two months have you taken any medicine (prescribed or not), alternative medicines or recreational drugs? *

NO, I'M NOT

YES, I AM, please specify:

Do you have any sensitivity to medicines or any allergies? *

NO, I'VE NOT

YES, I HAVE, please specify:

I confirm that I have read and understood this and my answers are fully correct and true. *

I CONFIRM

I DO NOT CONFIRM