Request for consultation for Low Dose Naltrexone (LDN)
LDN is a treatment used off label/license for autoimmune disease and certain cancers. It is an unlicensed medicine, so is generally only available privately. The consultation costs £35 and is with a General Practitioner. The medicine costs approximately £20.

At the end of this questionnaire, once you press SUBMIT, you will be requested to upload evidence of the disease you are wishing to be treated for. This can be a word document, a scan of a letter from your GP, a copy of your repeat prescription slip, consultant letter or any other evidence you can provide. If you don't have it to hand, don't worry - just skip the step and it can be provided later.

Email address
Are you resident in the UK or EU
Enter your Full Name
Your answer
Full Address
Your answer
Telephone Number
Your answer
Email address for confirmation:
Your answer
List all medicines you are taking, including supplements and vitamins.
Your answer
Brief medical history (What are you diagnosed and treated for? What other illnesses or conditions do you have?)
Your answer
Why do you want to try LDN? Which disease? (A list of conditions commonly treated with LDN is available here: https://www.ldnresearchtrust.org/conditions)
Your answer
Please give your current GP name and address so that our clinicians can contact them to verify your condition if necessary.
Your answer
Choose from below:
I agree to the following statement: I am formally giving Dickson Chemist and their direct clinical GP/NURSE partners permission to use the information I have given for my clinical care. I formally request to be registered as your patient for the purposes of this consultation.
I understand that Low Dose Naltrexone for autoimmune disease or cancer is an unlicensed medicine, used "off label" and as such there is limited clinical trial evidence to support the use of this medicine. (Standards we adhere to can be found here: https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities)
I am going to upload evidence of my clinical diagnosis on the next page (secure server)
A copy of your responses will be emailed to the address you provided.
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