Paihia Bombs Presale Questionnaire

This medicine is a “pharmacist only medicine”, which means we have to record the sale and make sure it’s safe for you or the people taking it.

The ingredients can interfere with some medical conditions and medicines.

Please completed the (yes/no) questions and medication list (if any) Below:

Name(Required)

Date of Birth(Required)

Best Contact Number

Email(Required)

Over 12 years?(Required)

Yes

For your own use?(Required)

Yes

Please list all medication you are currently taking(Required)

Are you on any herbal or vitamin supplements?(Required)

Any known Allergies?(Required)

Yes

Any other health conditions problems?(Required)

Yes

Pregnant or Breastfeeding?(Required)

Yes

Residential Address(Required)

Street Address Address Line 2 City Region Postcode Country

Is your postal address different to the one above?(Required)

Yes

Postal Address (if different to above)(Required)

Street Address Address Line 2 City Region Postcode Country

Paihia Bomb’s shouldn’t be given to anybody else without knowing their medical history etc.

We need to record the name and address of each person individually.

We’re limited to selling 10 caps per person @ $39.99 per 10 caps, plus postage of $12.00 (Within NZ Only)

Once you have submitted your questionnaire, we will contact you with any questions, once we are happy with your responses to the questionnaire, we will send you payment details.

Contact Us

Opening hours: Mon to Fri 8.30am to 5pm
Saturday: 9am to 1pm
Sunday: Closed
Extended summer opening hours December to Mid-February
Mon to Fri: 8:30am to 5pm
Saturday and Sunday: 9am to 3pm
Address: 4 Williams Road, Paihia, New Zealand
Phone 09 4027034
paihiapharmacy@xtra.co.nz