Book Allergy

Allergy - Medical Assessment

If you have ordered this medication before, you can log in here to fill up the questionnaire automatically. Our pharmacists have a few quick and easy questions to help issue your FREE online prescription.

About You

Are you registered with a GP practice in the UK?

Yes No

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).

Yes No

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

Yes No

Health

Have you been diagnosed with hayfever (seasonal allergic rhinitis) by a doctor or nurse previously?

Yes No

Are you allergic to Telfast (Fexofenadine)?

Yes No

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

Yes No

Have you been diagnosed with any of the following?

Kidney or liver problems
History of heart problems such as an irregular or fast heartbeat or angina or hypertension
Epilepsy
Glaucoma
Diabetes
Depression
Enlarged Prostate
Bladder problems (including difficulty in urinating)
Overactive thyroid

Yes No

Medication

Have you taken Telfast (Fexofenadine) previously or have you tried taking an over the counter anti-histamine without success?

Yes No

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

Yes No

Agreement

Do you understand there is a possibility that Telfast (Fexofenadine) may cause drowsiness and affect driving or operating machinery? You should check that these tablets do not make you feel sleepy or dizzy before driving or operating machinery.

Yes No

Do you understand you should stop taking Telfast (Fexofenadine) if your symptoms do not improve after 2 weeks of starting treatment?

Yes No

Do you understand that you should not take: Indigestion remedies (such as antacids) or Ulipristal (emergency contraception or treatment for fibroids) 2 hours before or after taking Telfast (Fexofenadine)?

Yes No

Do you agree to the following?

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 doctor or 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.

Yes No

Allergy - Medical Assessment

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?

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

Have you been diagnosed with hayfever (seasonal allergic rhinitis) by a doctor or nurse previously?

Are you allergic to Telfast (Fexofenadine)?

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

Have you been diagnosed with any of the following?

Have you taken Telfast (Fexofenadine) previously or have you tried taking an over the counter anti-histamine without success?

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

Are you taking any of the following medications?

Do you understand there is a possibility that Telfast (Fexofenadine) may cause drowsiness and affect driving or operating machinery? You should check that these tablets do not make you feel sleepy or dizzy before driving or operating machinery.

Do you understand you should stop taking Telfast (Fexofenadine) if your symptoms do not improve after 2 weeks of starting treatment?

Do you understand that you should not take: Indigestion remedies (such as antacids) or Ulipristal (emergency contraception or treatment for fibroids) 2 hours before or after taking Telfast (Fexofenadine)?

Do you agree to the following?