I AM Questionnaire

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1 .Name of Parent/Guardian

Address

2. Name of Patient

Address of Patient

Patient DOB

Prescribing Doctor

3. Route through which medication is received

GP Private clinic Other

4. Name of facility through which the medication is received

5. Name of medication currently received

Formulation of medication currently received (if known)

Dosage of medication

How many times per day

Size/Volume of medication currently received

I have read and accept the privacy policy and give I Am Billy permission to store and process all data on this form. Disclaimer: Data will be used by IAB to ascertain whether the patient is eligible for the receipt of gifted medication . Your data will not be shared with any third party (including the medical manufacturer) without the consent of parent/guardian.

I AM Questionnaire

Get in Touch. We are here for you!

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