Are you registered with a GP practice in the UK?

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.)

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

Do you currently suffer with heartburn, indigestion or acid reflux?

How long have you suffered from acid reflux/heartburn?

Have you had this condition diagnosed by a doctor?

Are you experiencing symptoms of acid reflux at least twice a week?

Do you experience food sticking in your throat/food pipe after swallowing?

Do you cough up blood?

Are you pregnant or breastfeeding?

Do you have any liver or kidney problems?

Do you suffer with any of the following symptoms:

• A sore, inflamed oesophagus (oesophagitis).
• Indigestion or heartburn that wakes you up.
• Indigestion or heartburn that radiates through to your back.
• Feeling or being sick.
• A sore throat and hoarseness.
• A persistent cough or wheezing, which may be worse at night.
• Tooth decay and gum disease.

Do any of the following apply:

• You are over 65 years of age.
• You are aged 55 years or over & have had symptoms for the first time in the last 12 months or that are worsening or changing.
• You have experienced unintentional weight loss
• Difficulty or pain on swallowing.
• You suffer with anaemia.
• You have experienced vomiting, particularly if there is blood in the vomit, previous gastric ulcer, surgery or jaundice.
• You are experiencing bleeding from the rectum (especially if the blood is darker in colour) or dark/sticky stools.

Do you to agree to consult your doctor in the following circumstances:

• If your symptoms change or get worse.
• If your treatment no longer relieves your symptoms.
• If your symptoms do not settle within five days of treatment.
• If you experience any side effects from your treatment.

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

Do you take any of the following medicines:

• Nelfinavir, atazanavir or saquinavir (to treat HIV).
• Antifungal treatments (such as itraconazole or ketoconazole).
• Digoxin (to treat heart problems).
• Diazepam (to treat anxiety).
• Phenytoin (to treat epilepsy).
• Warfarin or other anticoagulants.
• Rifampicin (to treat TB).
• Tacrolimus (to prevent transplant rejection).
• St. John's Wort (to treat mild depression).
• Cilostazol (to treat muscle pain/cramp).
• Clopidogrel (to prevent blood clots).
• Erlotinib (to treat cancer).
• Methotrexate (to treat rheumatism and cancer).

• 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.