1
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?

NoYes

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?

NoYes

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:

Kidney problems,
Hormone or sugar problems?(e.g. diabetes, thyroid problems),
Neurological problems?(e.g. parkinsons, previous stroke or mini-stroke).
Liver problems?(e.g. hepatitis, fatty liver, alcohol liver disease),
Breathing problems?(e.g. asthma, COPD, bronchiectasis),
Mental health problems?(e.g. anxiety, depression, personality disorder) or
Thyroidectomy (removal of thyroid)
Or any other diagnosed conditions.

NoYes

Please provide more details

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

NoYes

Please provide more detail.

Do you have any allergies to medications or any other substances?

NoYes

Please list everything you are allergic to and what symptoms you experience.

Do you take or use any recreational drugs?

NoYes

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?

NoYes

Please provide more detail.

2
Medical Questions

You can order PrEP medication if you are HIV negative and have a higher risk of getting HIV. Please do not order medication for anyone else including a sexual partner. Unfortunately we cannot prescribe PrEP if you are already pregnant.

Once you complete this consultation, one of our prescribers will review your responses to check that treatment is suitable.

If you are HIV positive, or you think you have been exposed to HIV recently, you should go to a sexual health clinic for advice and treatment instead.

I am aware that If I think I’ve been exposed to HIV in the last 72 hours, I should visit my local sexual health clinic straight away. They can prescribe me PEP (post-exposure prophylaxis) instead to help prevent infection. If a clinic is unavailable, I will go to A&E instead.

Confirm

Are you currently using PrEP?

This could be either daily or on demand PrEP. We wouldn’t consider you a current user if you’ve used PrEP before but have since stopped.

Have you taken PrEP before?

NoYes

Please tell us when you took PrEP and why you stopped.

Do not have unprotected sex if you have run out of PrEP (or about to run out). You may not be protected against HIV until you restart PrEP.

Confirm

When was your last PrEP dose?

When did you start taking PrEP?

Have you had unprotected sex since your last dose of PrEP?

You may be at risk of getting HIV if you’ve had unprotected sex since you had your last dose of PrEP. You should wait 6 weeks and take an HIV test to make sure you’re negative before restarting PrEP.

NoYes

When did you take your last PrEP dose?

When was your last HIV test?

When were you last tested for STIs (sexually transmitted infections)?

Did you have a normal kidney function test result before starting PrEP, or since you’ve been on PrEP?

NoYes

Please tell us when you had your last kidney function test.

Do you have any liver or kidney conditions?

NoYes

Please provide more details.

Do you have any hereditary problems of galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption?

NoYes

Are you allergic to any of the following:

Tenofovir
Emtricitabine
Peanuts or Soya
Lactose

NoYes

Please provide more details.

I understand that:

I have a risk of HIV but am not currently HIV positive.
I should take a full STI screen test every 3 months to check my HIV and hepatitis status as PrEP does not offer 100% protection, though it is highly effective.
I must check kidney function whilst taking PrEP. There is a small risk of kidney damage, thought it is rare.

Confirm

3
Consent

Would you like us to notify your GP of the treatment you chose to order today?

NoYes

Please provide details.

Doctor Surgeries

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I can't find my surgery and would like to edit the address below.

Please enter your GP details below

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:

You understand the prescriber will 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 a soft check to validate your identity via LexisNexis
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

NoYes

Sorry we can't offer you this treatment, please contact your GP.

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.

Assessment

Trust Pilot

Medical Questions

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Medical Questions

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Confirm treatment selection

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Information

Customer care

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Assessment

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Medical Questions

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