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.
Are you currently:
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.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Are you aged between 18 and 60 years old?
Please confirm your age
Have you or a sexual partner been diagnosed with gonorrhoea by a GP, at a GUM clinic or tested positive with a home test kit?
Why are you requesting treatment today?
Please upload an image of your positive test result if this is applicable. This will aid us in making an appropriate clinical decision when prescribing
*Please note, this is OPTIONAL*
Are you aware that we can only provide treatment for one person per registered account?
If your sexual partner also requires treatment, they will need to register their own account with their own email address and medical details.
Multiple orders from the same account will be cancelled and refunded.
Do you have any concerns about your sexual partner(s) or your relationship that you would like to discuss privately with a member of our healthcare team?
Are you experiencing any of the following symptoms:
Are you aware you should refrain from sexual contact for 14 days after taking treatment, until no longer infectious and that you must inform all previous sexual partners in the last 6 months of your diagnosis?
Do you understand that:
Do you have any allergies to Cefixime or Azithromycin?
Do you have a penicillin allergy?
Have you been diagnosed with any of the following?
I understand that:
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:
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.
We use cookies to give you the best online experience. By using our website you agree to our use of cookies in accordance with our cookie policy.