Escape Travel Sickness 1300 SEASICK

Order Sea and Motion Sickness Treatment (Patient assessment form)

We have earned a reputation for assisting patients in treating sea and motion sickness. The medical questionnaire form will assist our qualified staff in undergoing a risk assessment to ensure the most suitable treatment is provided to you. After receiving your online inquiry, one of our friendly staff will promptly contact you to assist with your treatment needs.

Alternatively, for immediate assistance you can contact us on 1300 SEASICK for further information during business hours and speak to one of our travel sickness specialists.

* Indicates required field

Order Form

Name*

Have you used any motion sickness medication before (either prescription or non-prescription medication)? *

YesNo

If yes, what medications have you used before for motion sickness?

Have you experienced undesired side effects such as drowsiness from motion sickness medication you have used in the past or have you found the medication to be ineffective for you?

YesNo

Have you used medication supplied by our pharmacy for motion sickness before? *

YesNo

Who is this medication for? *

SelfOthersSelf & Others

If you selected ‘Others’ or ‘Self & Others’ please detail the individuals who will be using this medication*

What are the ages of the individuals requiring treatment? *

Over 18Under 18

If you selected ‘Under 18’ please tell us the ages of any individual below 18*

Is any person requiring treatment pregnant or breastfeeding? *

YesNo

Is any person requiring treatment currently using any other medication? *

YesNo

If yes, please list all medications being used?*

Is any person requiring treatment suffering from any allergies? *

YesNo

If yes, please list the allergies*

Is any person requiring treatment suffering from any medical conditions? *

YesNo

If yes, please list the medical conditions*

Contact Details*

When do you require your medication? *

THIS SOUNDS PERFECT! Please call me to discuss a personalised solution...

Worried about your cruise? Worried about an upcoming fishing trip? Escape motion sicknes and order now