Practitioner Product Policy & Compliance
I confirm that this product has been prescribed or recommended this product by a qualified healthcare practitioner.
☐ Yes
☐ No
I confirm that I have used this product under practitioner guidance or am using it for a condition discussed with one.
☐ Yes
☐ No
I confirm that I have previously discussed this health concern with a practitioner (either at this clinic or elsewhere).
☐ Yes
☐ No
I confirm that I disclosed any prescription medications or supplements I am currently taking.
☐ Yes
☐ No
I confirm that I understand this product must be used only as directed and that I will seek our practitioner advice if symptoms persist or worsen.
☐ Yes
☐ No
Medical Conditions
I confirm that I have disclosed any relevant medical conditions, allergies, or health concerns that may affect the safe use of this product.
☐ Yes
☐ No
Pregnancy and Breastfeeding
I confirm that I have informed the practitioner if I am pregnant, planning pregnancy, or breastfeeding, where relevant to this product.
☐ Yes
☐ No
Understanding Product Limitations
I understand that this product is intended to support health and wellbeing and is not a substitute for medical diagnosis, treatment, or emergency care.
☐ Yes
☐ No
Following Dosage Instructions
I agree to follow the recommended dosage, storage instructions, and usage guidelines provided with this product.
☐ Yes
☐ No
Consent to Practitioner Follow-Up
I consent to being contacted by the clinic or practitioner if additional information is required to ensure the safe and appropriate use of this product.
☐ Yes
☐ No
Practitioner Product Declaration
☐ I confirm that the information provided in this form is accurate and complete to the best of my knowledge.
☐ I understand that practitioner-only products may not be suitable for all individuals and are supplied based on the information provided.
☐ I acknowledge that North Shore Health Clinic may request additional information or recommend a consultation before approving access to practitioner-only products.
☐ I agree to follow all dosage, usage, and storage instructions supplied with these products.
☐ I understand that practitioner-only products are intended for my personal use only and should not be shared, resold, or supplied to others.
☐ I understand that approval to purchase practitioner-only products is at the discretion of North Shore Health Clinic and its practitioners.
Clinic & Brand Compliance Statement
North Shore Health Clinic supplies practitioner-only products in accordance with the professional requirements of our affiliated healthcare practitioners and supplier brands. These products are intended to be used under appropriate practitioner guidance and clinical oversight. The clinic reserves the right to decline, restrict, or review access to practitioner-only products where additional information or consultation is considered necessary to ensure safe and appropriate use.
Patient Acknowledgement
☐ I acknowledge and agree to the Practitioner Product Policy and Compliance Statement.
