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
Please list all the allergies you suffer from (eg. food, insect bites etc.)
Have you ever been advised by your doctor or specialist to carry an adrenaline injector (EpiPen or Jext) with you in the event of an anaphylaxis?
Why are you requesting this treatment today?
Why do you require an adrenaline injector?
When did you first get prescribed an adrenaline auto-injector?
What is the reason you require an adrenaline auto-injector?
Have you used an adrenaline injector due to an episode of anaphylaxis?
Please tell us when the last time you used the adrenaline injector
Have you recieved training on how to use your adrenaline injector if an episode of anpahylaxis occurs?
Please provide more information
Are you confident in recognising the signs and symptoms of anaphylaxis?
You must agree that everytime you use an adrenaline injector to treat anaphylaxis, you must call 999 so that you can be seen by an emergency medical practitioner to assess your symptoms
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.