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

Medical Assesment Thrush

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

Why do you feel you need treatment for thrush?




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Please choose all the symptoms that you are currently experiencing







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Have you used treatment for thrush in the last 4 weeks?



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How many times have you had thrush in the last 12 months?



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Health

Do you suffer from any problems with your kidneys, your urinary system or with your liver?

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Are you pregnant or planning to become pregnant or breastfeeding?

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Do you have any allergies to any medicines or any other allergies in general, including lactose (milk)?

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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.