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You will get a free prescription issued by our doctors.

Note: By continuing with this order, you confirm that you are over the age of 18 and have the mental capacity to make decisions for your health.If your consultation is approved, you will be offered treatment for you and the prescriber to jointly consider. However, the final decision always will be the prescriber's.

Learn more about Herpes on the NHS website.

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ABOUT YOU

Are you aged between 18 and 65?

Have you been diagnosed by your GP or GUM clinic with Genital Herpes (HSV-1 or HSV-2)?

YOUR SYMPTOMS

Are you experiencing any of the following?

  • thrush
  • unintentional weight loss
  • chest pain
  • blood in your urine
  • pain when urinating
  • blood in your stools
  • urinary tract infections (UTI)
  • night sweats
  • fever

YOUR HEALTH

Do you have an allergy (hypersensitivity) to medicines containing Aciclovir or Valciclovir or Famciclovir or Penciclovir?

Are you breastfeeding or pregnant or possibly pregnant?

Have you been diagnosed with any of the following?

  • Liver problems
  • Kidney problems
  • Immunodeficiency conditions (eg. HIV)
  • Nervous system abnormalities
  • Any serious medical condition which may require immediate hospitalisation

YOUR MEDICATION

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

AGREEMENT

Do you understand that you should maintain genital hygiene and avoid sexual contact during your outbreak?

Do you understand that you should drink water regularly during your treatment? This will help reduce side effects that can affect your kidneys or nervous system.

Do you understand that if your symptoms do not improve after 7 days you must see your doctor?

Fill in this field if you would like us to notify your GP surgery.

Do you agree with the following?

  • You will read the patient information leaflet supplied with your medication
  • 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.
  • The treatment is solely for your own use
  • You give permission to access you NHS Summary Care Record in order to identify you correctly, check your medical history and provide the best possible care.
  • You give permission to contact your GP to inform them of your treatment.
  • 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.
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