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
Why do you need treatment for Bacterial Vaginosis (BV)?
Please provide more information below.
e.g: online research via websites such as WebMD or at-home test kit
Which of the following symptoms are you experiencing?
You can select more than one
Are you suffering from abdominal pain?
If the pain is moderate or severe can you please tell us more.
For example:
Do you have abnormal vaginal bleeding?
If you have frequent or heavy bleeding between periods, please tell us more so that we can advise.
Have you suffered from more than FOUR cases of BV in the last 12 months?
Please provide us with more informatin about your condition so that we may be able to help you.
Do you have an IUD (Intra-uterine device) fitted?
An IUD is used for contraception.
Please provide more information, such as which IUD you have had fitted and for how long
Do either of the following apply:
If you have had unprotected sex with a new partner within the last 2 months, have you had an STI test to rule out symptoms being caused by an STI?
Could your symptoms be caused by a tampon that has been retained?
A retained tampon could also cause unpleasant smelling discharge.
Please provide more information
Do you agree to see your doctor if:
Have you successfully used this treatment to treat Bacterial Vaginosis in the past?
Do you take any of the following medicines:
Have you had any gynaecological examinations or procedures recently?
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.
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