Asthma Form

US$ 10,00

Easily & affordably receive 6 month prescriptions for your Asthma treatment.

Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways, leading to difficulty breathing. Asthma symptoms include wheezing, shortness of breath, chest tightness, and coughing, especially at night or early in the morning.

The cost of medication is not included in this prescription

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Name

Surname

Phone Number

ID Number

Have you used our services before?

Address

City

Postal Code

When were you diagnosed with Asthma and who was the diagnosis made by?

What asthma medication are you requesting a repeat of? (include concentration/dose)

How often do you use each of your asthma medications?

Is your asthma well controlled with your treatment?

Do not continue

When was your last asthma attack?

How often do you experience wheezing, shortness of breath, difficulty breathing, chest tightness or waking up at night from your asthma?

Are you currently pregnant or breastfeeding?

Do not continue

Do you have any other medical conditions?

What medical conditions do you have?

Are you currently taking any other medication?

What medication are you taking?

Do you have any allergies including allergies to medication?

What allergies do you have?

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service. I understand the questions above and have answered honestly. I understand that any inaccurate or false information could potentially be dangerous to my health and safety. The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.I agree to the Terms & Conditions of this platform.I am 18 years or older.I am currently living in Zimbabwe

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

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US$ 10,00