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
Are you aged between 18 and 60 years old?
Please provide your age
How do you know that you need chlamydia treatment?
If you have diagnosed your condition by yourself, can you please provide us more detail on how you have done this.
For example:
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?
Please provide more details
Are you experiencing any of the following symptoms:
Please provide more information
Are you aware you should refrain from sexual contact for 7 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 the ingredients in Azithromycin or Doxycycline?
Please confirm that you understand that in line with national guidelines for clinical excellence Doxycycline is the first-line treatment for chlamydia infection and you should only opt to take azithromycin if you have an allergy or have had negative side-effects from doxycycline in the past
If you have opted to take Azithromycin instead of Doxycycline to treat your chlamydia infection, what is the reason for this?
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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