Mon - Fri: 9am - 7pm Sat: 9am - 6pm

   020 8654 1149  215 Lower Addiscombe Rd, Croydon CR0 6RB

Minor Illness Assessment

Please complete this short questionnaire before your consultation. This helps our pharmacist understand your symptoms and medical history so we can provide the most appropriate advice, treatment, or referral if necessary.

*This is a private prescribing service. Consultation and treatment fees may apply.

Larchwood Pharmacy, Croydon

How Our Private Assessment Works

1. Complete the Online Assessment

Fill in our secure clinical questionnaire so our prescribing pharmacist can review your symptoms.

2. Pharmacist Review & Contact

A qualified pharmacist will assess your information and contact you to discuss your needs.

3. Receive treatment or advice

You may receive treatment remotely where appropriate, or be invited to attend the pharmacy for further assessment.

Private Clinic Consultation Form

Private Clinic Consultation Form

Please complete this form before booking your consultation. This helps our pharmacist understand your symptoms and determine the most appropriate treatment or advice during your appointment.

All information is confidential and will only be used for your consultation.

Personal Details

Please provide accurate personal details. This information allows us to verify your identity, assess medication or treatment suitability.

All information is handled confidentially in accordance with UK data protection regulations.

Consultation Type

Respiratory / Infectious

Gastrointestinal Issues

Skin Conditions

Chronic / Systemic

Other Common Issues

Symptoms

Medical History

Please select any conditions that apply to you, past or present. This helps our pharmacist understand your overall health.

Allergies

Additional Information

Informed Consent

I confirm that the information provided is accurate and complete.

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