Your health and safety are our top priorities. To ensure we provide you with the most effective and appropriate treatment, it is crucial that you provide accurate and complete information about your health during our online consultation process. Accurate information helps us understand your condition better, assess any potential risks, and recommend the best possible medication for your needs. Providing false or incomplete information can lead to inappropriate treatment, potential health risks, and delays in receiving the care you need. Thank you for your cooperation and trust in our services.

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Male
Female
Transmale (Born a female)
Transfemale (Born a male)







Liver disease
Kidney disease
Gastrointestinal perforation or obstruction
Gastrointestinal haemorrhage
Confirmed or suspected pheochromocytoma
History of neuroleptic or metoclopramide-induced tardive dyskinesia
Epilepsy
Parkinson’s disease
Methaemoglobinaemia or NADH cytochrome-b5 deficiency
QT interval prolongation or cardiac conduction disorder
Bradycardia or electrolyte imbalance
Rare hereditary problems of galactose intolerance, Lapp lactase deficiency, or glucose-galactose malabsorption
None of the above

  • Levodopa or dopaminergic agonists
  • Anticholinergics or morphine derivatives
  • CNS depressants (e.g. anxiolytics, sedating antihistamines, sedative antidepressants, barbiturates, clonidine)
  • Neuroleptics
  • SSRIs or serotonergic drugs
  • Digoxin
  • Cyclosporine
  • Strong CYP2D6 inhibitors (e.g. fluoxetine, paroxetine)"




Accurately describing your condition during our online consultation is essential for ensuring you receive the best possible care. Detailed and truthful information about your symptoms, their frequency, and their severity allows our healthcare professionals to make informed decisions about your treatment. Incomplete or incorrect descriptions can result in inappropriate medication, potential health risks, and delays in your care. Your honesty and thoroughness help us provide you with the most effective and safe treatment options. Thank you for your cooperation and trust in our services.

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If yes, did you experience any side effects?


If yes, please specify




Please take the time to carefully read the Agreement and Consent statements during our online consultation process. Understanding these statements is essential for your safety and for ensuring that you are fully informed about the treatment you will receive. The Agreement and Consent sections outline important information about the risks, benefits, and responsibilities associated with your medication. By reading and agreeing to these terms, you help us ensure that you are aware of and comfortable with the treatment plan. Your informed consent is crucial for providing you with the best possible care. Thank you for your cooperation and trust in our services.

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  • I confirm that the information I have provided in this form is accurate to the best of my knowledge.
  • I understand that providing false or incomplete information may affect the safety of my treatment.

  • I understand that metoclopramide is used to relieve nausea and vomiting, particularly when associated with migraine.
  • I understand that it may cause side effects such as drowsiness, dizziness, or involuntary movements, especially with repeated use.
  • I confirm I will not take more than the recommended dose or use it for longer than advised.
  • I have read and understood the Patient Information Leaflet provided with this medication.

  • I agree to report any side effects such as involuntary movements, severe drowsiness, or allergic reactions to a pharmacist or GP.
  • I understand that this medication should not be used for prolonged or repeated treatment without medical supervision.
  • I will seek medical advice if symptoms worsen or fail to improve after treatment.

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.I understand that my information will be kept confidential and used solely for the purpose of this assessment. 

  • I am requesting metoclopramide for the relief of nausea and/or vomiting associated with migraine.
  • I have had the opportunity to ask questions and understand the risks and benefits of the treatment.
  • I accept full responsibility for using this medication as advised.