1
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?

NoYes

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?

NoYes

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

NoYes

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

NoYes

Please provide more detail.

Do you suffer from any allergies?

NoYes

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?

NoYes

Please provide more detail.

2
Medical Questions

Are you suffering from nausea or vomiting?

NoYes

Why are you requesting treatment today?

Has your nausea or vomiting been persistent for more than 3 days?

NoYes

Please provide more details

Are you pregnant, breastfeeding or trying to have a baby?

NoYes

Please provide more details

Have you used this medication before?

NoYes

Please provide more details

Are you able to keep fluids down?

NoYes

Please provide more details

Do you have stomach cramps, fever, yellow or green bile when you vomit, blood or dark flecks in your vomit or pain in your upper abdomen spreading into your back?

NoYes

Please provide more details

Do you have any underlying heart disease?

NoYes

Please provide more details

Do you have any conditions that might or do affect the conduction of your heart?

NoYes

Please provide more details

Are you taking any medication for your heart?

NoYes

Please provide more details

Do you have a disease that affects your liver, liver function, kidney or kidney function?

NoYes

Please provide more details

I am are aware that treatment for nausea and vomiting should NOT be taken long term and is only indicated for acute (sudden) nausea and vomiting. Any ongoing issue should be assessed by my GP

Confirm

3
Consent

Would you like us to notify your GP of the treatment you chose to order today?

NoYes

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:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

NoYes

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.

Assessment

Trust Pilot

Medical Questions

2
Medical Questions

3
Consent

Confirm treatment selection

Useful links

Information

Customer care

External Links

Here to help

Assessment

Trust Pilot

Medical Questions

2Medical Questions

3Consent

Confirm treatment selection

2
Medical Questions

3
Consent