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  1. Home
  2. Chlamydia Treatment
  3. Raf
1. Assessment Form
2. Choose Treatment
3. Your Order
4. Finish

Medical Assesment Chlamadia treatment (Doxyclycle and Azithromycin)

About You

Are you registered with a GP practice in the UK?

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Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

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Do you believe you have the capacity to make decisions about your own healthcare?

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You must have the capacity to make decisions about your own healthcare to proceed. Please see your GP
Symtoms

Have you had sex with more than one sexual partner in the last 3 months?

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This medication is not suitable for you. Please consult your GP.

How do you know that you need Chlamydia treatment?





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Please let us know if you have any of the following symptoms? (You don't have to have symptoms to get treatment).









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Health

Do you have any concerns about your relationship or sexual partner(s) that you would like to discuss privately with a healthcare professional?

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Are you currently pregnant or breastfeeding?

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This treatment is not suitable for use in pregnancy or breastfeeding. Please consult your GP.

Are you HIV positive?

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Do you have any conditions affecting your kidneys, urinary system or kidney function?

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It is important that you contact your sexual partner(s) to let them know that they may have caught chlamydia. Would you like us to help you contact partners anonymously?

This field is required.

Are you aware you should refrain from sexual contact for 7 days after treatment has been completed, until no longer infectious?

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Are you aware, after treatment, it may take up to 14 days for symptoms to go?

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Are you aware Azithromycin and Doxycycline does not treat all sexually transmitted disease?

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Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

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Agreement
  • I confirm I am over 18 years old.
  • The medicine ordered is for my sole use only.
  • I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
  • You have answered all the above questions accurately and truthfully. You understand our prescribers 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 an ID check to verify your ID via LexisNexis Risk Solutions.
This field is required.
You must click on the terms and conditions to continue
The decision about the treatment offered is for both the prescriber and patient to jointly consider. However, the final decision will always lie with the prescriber which will ensure patient safety is not compromised. If treatment is refused, you will be signposted to another service and given a full refund.