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.
Are you currently:
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.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Please tell us which continent you will be visiting.
Select one or more answers.
Please can you tell us which country or countries you will be visiting?
Please can you tell us the nature of your trip?
Please can you tell me more about the nature of your trip?
Have you ever taken antibiotics to treat Traveller's Diarrhoea before?
Please tell us more:
When and which type of medication did you take?
Did you experience any side effects?
Do any of the following apply:
Have you read and understood the information provided on how to prevent travellers' diarrhoea?
Do you agree to see a doctor if:
Are you allergic to Azithromycin or Erythromycin, any other drug known as a macrolide or Ciprofloxacin?
Do you take any of the following medicines?
Please provide further details
I am aware that Traveller's Diarrhoea should start to improve within 24 hours of starting antibiotics and I should complete the full course of antibiotics prescribed:
Do you understand that using Azithromycin for Travellers Diarrhoea is an off-license use of this product?
Medicine used off-license means the manufacturer is not liable in case of adverse events. Instead, prescribers take responsibility for the prescribing.
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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