Book Cold Sore

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

Are you aged between 18 and 65?

Yes No

Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?

Yes No

Symptoms

Do you have any of the following symptoms:

Mouth ulcers /lumps lasting more than 3 weeks
Painful red and white patches on the inside of the mouth
Fluid filled blisters/crusts on the lips

Yes No

Health

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

Yes No

Are you pregnant, breast feeding or possibly pregnant?

Yes No

Have you been diagnosed with any of the following conditions?

Liver problems
Kidney problems
Any condition affecting the immune system i.e. cancer, HIV etc
Nervous system abnormalities
Electrolyte abnormalities
Any serious medical condition which may require immediate hospitalisation

Yes No

Medication

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

Yes No

Agreement

Do you understand that outbreak treatment should be initiated at the earliest symptom of a cold sore eg tingling, itching or burning sensation?

Yes No

Do you understand that if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?

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

Cold Sore - 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?

Are you aged between 18 and 65?

Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?

Do you have any of the following symptoms:

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

Are you pregnant, breast feeding or possibly pregnant?

Have you been diagnosed with any of the following conditions?

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 that outbreak treatment should be initiated at the earliest symptom of a cold sore eg tingling, itching or burning sensation?

Do you understand that if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?

Do you agree to the following?