Are You An Existing Patient ?YesNo Address What would you like to Request/Order?

Please outline the medication, service or blood referral type you would like to reorder/order (this is for existing patients only)

What was your last Blood Pressure Reading?  Describe your current Health status Including any medical issues or Side Effects to Medications  List any hormonal medications you are taking Do you use any cannabis? —Please choose an option—YesNo

Please list any medications that have been ceased as well

The individual filling out this form and/or who's Identification has been supplied consents and/or agrees to Zenda Healthcare, its Director, Staff, Contractors and associated partners to act as their agent. You agree to giving consent for the agent to act on your behalf with Doctors, Pharmacists, Allied Health Professionals within the interest of your enquiries and in accordance with the Australian Privacy Act. You acknowledge that you understand the team at Zenda Healthcare comprise of contractors and Admin staff who are not Doctors and can't/will not provide medical advice. You agree for the team to act as an agent in liaising with your Doctor/s, the pharmacies and other partis at your instruction and in your best interests.

Please Note: Body Enhancement/Performance Enhancement is not a suitable goal and tratment will not be prescribed by a doctor for this purpose*I agree to attend my regular Doctor (GP) or Specialist for full heath CheckI agree to have any checks they deem necessary including but not limited to, Blood pressure, Cholesterol, Heart Check, ECG, Physcial examination, Pathology Request Agent Agreement Confirmation

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By Filling this form, I agree to only using the medication/treatment prescribed to me, if any, in the correct and safe manner as ordered by the Doctor. I agree that the information and medication are only for me and that I will not sell, share or distribute medication/protocol to any other parties. I agree to use medication at the prescribed dose only and to report any side effects or adverse reactions to the pharmacy.