Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Are you aged between 18-65 years old?
Please confirm your age
Have you been diagnosed with Genital Herpes (HSV-1 or HSV-2) by your GP or GUM clinic?
Why are you requesting this treatment?
We recommend that you consult your GP or local GUM clinic if you have not done so already.
Do you have an allergy (hypersensitivity) to this medication?
Please provide more details
Are you breastfeeding or pregnant or possibly pregnant?
Have you been diagnosed with any of the following?
Do you understand that you should maintain genital hygiene and avoid sexual contact during your outbreak?
Do you understand that you should drink water regularly during treatment to reduce any possible effects on kidneys or your nervous system?
Are you aware you should seek medical advice if sores are getting worse or are not healing after 10 days?
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
Sorry we can't offer you this treatment, please contact your GP.
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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