Medical Assessment - Herpes

About You

Are you aged between 18 and 65?

We are unable to treat you if you are outside this age range. Please consult your GP or your local GUM clinic.
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Have you been diagnosed by your GP or GUM clinic with Genital Herpes (HSV-1 or HSV-2)?

We are unable to treat you if you have not been diagnosed. Please consult your GP or your local GUM clinic.
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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
Consult your GP urgently. These symptoms indicate the possibility of a more serious illness.
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Health

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

We are unable to supply you with treatment. Please consult your GP.
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Are you breast feeding or pregnant or possibly pregnant?

We are unable to supply you with treatment. Please consult your GP.
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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
We are unable to supply you with treatment. Please consult your GP.
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Medication

Are you taking any of the following medications?

  • cimetidine (used to treat peptic ulcers)
  • probenecid (used to treat gout)
  • raloxifen
  • medicines that suppress your immune system (e.g. mycophenolate mofetil; ciclosporin; tacrolimus; methotrexate)
  • theophylline and aminophylline (used in asthma and other breathing problems)
  • zidovudine (used in HIV infection)
  • any medicine which affects the kidneys, including aminoglycosides, organoplatinum compounds, iodinated contrast media, pentamidine, foscarnet
We are unable to supply you with treatment. Please consult your GP.
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Agreement

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

We are unable to supply you with treatment. Please consult your GP.
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Do you understand that you should drink water regularly during your treatment? This will help reduce side effects that can effect your kidneys or nervous system.

We are unable to supply you with treatment. Please consult your GP.
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Do you understand that if your symptoms do not improve after 7 days you must see your doctor?

If your symptoms persist you may have a more serious illness. Contact our helpline for more information
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Do you agree to 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 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 must agree to this before continuing. If you need assistance contact customer support.
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