Product Risk Assessment Form

Please fill out all of the entry fields labelled with *.

Product Risk Assessment Form - a pre-requisite for clients' safety and health being.

Many medicines and natural supplements are now regulated and restricted to professional use only, available only after a professional assessment of the risks and benefits of the product on an individual basis.

Newtons' pharmacy practitioners are obliged, by the requirement for the exercise of professional duty of care, to perform such assessment for all restricted products.

Newtons Pharmacy respects your privacy and is bound by the National Privacy Principles set out in the Privacy Act 1988 of the Commonwealth of Australia. This form will not be entered into a digital database or shared with a third party.

Please advise us if you have concerns or problems regarding completing this form as we may be able to offer an alternative solution.

Thank you for your cooperation.

Your email address *

Name *

Please put down your first and last name.

Product of Interest *

Please indicate which product you are interested in purchasing or more information.

Has this product been prescribed from a health professional? *

Yes No

Health Concern *

Please indicate what will this product be used for.

Allergies *

To help us guard you against adverse effects, please indicate if allergic to any medicines, food groups or plants, such as daisies or tomatoes.

Current Health Conditions *

To help us guard you against contraindications, please list your current health conditions, if any.

Concurrent Medicines or Supplements *

To help us guard you against drug interactions, please list your current prescription and non-prescription medicines:

Are you pregnant? *

Yes No

Your answer helps to assess risk to both mother and child.

Are you on blood thinning prescription drugs *

Yes No

SenderName *

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