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?
Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?
How do you know you have cold sores?
Please upload a picture of your cold sores, if this is on the face, please include a picture showing the full face.
*A picture will help our healthcare team to make an appropriate decision about your treatment but it is not compulsory*
Do your cold sores appear only around the mouth or lips?
Where are your cold sores located?
Do you experience any symptoms other than:
Please describe your symptoms in full
Have you ever been told that you have HIV or a weakened immune system?
Please provide futher information about your condition
Do you have any of the following symptoms:
Please describe your symptoms
Do you have an allergy (hypersensitivity) to medicines containing Aciclovir, Valciclovir, Famciclovir or Penciclovir?
Please provide information about your allergy
Do you understand that treatment of the outbreak should be initiated at the earliest symptom of a cold sore e.g tingling, itching or burning sensation?
Do you agree to see your doctor or practitioner if:
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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