Genital Herpes Prescription

Your Health

Are you aged between 18-65?

Yes No

Has a GP or sexual health clinic ever diagnosed you with genital herpes before?

Yes No

Are you experiencing any of the following symptoms:

Thrush
Chest pain
Urinary tract infection (UTI)
Pain when urinating
Blood in urine
Bood in stools
Fever
Night sweats
Unintentional weight loss

Yes No

Do you have a known allergy or hypersensitivity to aciclovir, valaciclovir, famciclovir, penciclovir, or any of the excipients in these medications?

Yes No

Are you pregnant or breastfeeding?

Yes No

Medical Conditions

Do you have any of the following medical conditions:

Kidney problems
Liver problems
Immunosuppression (for example if you have conditions such as HIV which cause immunodeficiency)
Nervous system disorders
Previous organ transplant

Yes No

Medication

Do you take any of the following medications:

Probenecid
Cimetidine
Medication that suppresses the immune system (e.g. mycophenolate mofetil, methotrexate, ciclosporin, tacrolimus)
Medicines that affect the kidneys (aminoglycosides, organoplatinum compounds, iodinated contrast media, pentamidine and foscarnet)
Colistimethate
Theophylline or aminophylline
Zidovudine

Yes No

Agreement

Are you aware that if you experience 6 or more outbreaks a year, you may be in need of suppressive antiviral treatment? This would be a daily treatment at a lower dose of the same medication. The full suppressive effect would only be seen from day 5 of treatment. If you are interested in this treatment, please request the suppression treatment in the treatment selection page. This treatment cannot be selected if you have less than 6 outbreaks a year.

Yes No

Do you understand that you should maintain genital hygiene and avoid having sex until all your symptoms have disappeared? You should also use a condom after symptoms have cleared to avoid spread of the virus.

Yes No

Do you understand that you should see your doctor if symptoms do not improve with treatment or worsen during treatment?

Yes No

Do you agree to the following:

You will read the patient information leaflet before using this medication
You are aged 18 years or over
You have answered all questions truthfully and accurately
If you have an NHS Summary Care digital record, our specialists can check it to ensure this medication is safe for you
You understand that we take your answers in good faith and any false or incorrect information given can be hazardous to your health
This treatment is solely for your own use
You will inform your GP that you have been prescribed this medication if this is appropriate
You will contact us and inform your GP if you experience any side effects with your treatment, you start any new medication/your medical conditions change during treatment
You are capable of making your own decision about your healthcare and have the capacity to do so

Yes No

GP Details

We can notify your GP of your treatment for you. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to YourMedicals contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Verify your BMI

To comply with regulations and ensure the safe provision of weight loss treatment, we need to verify your BMI. You may complete this step later, but we cannot proceed with your prescription until it is provided.

Upload Now Upload Later

Upload Your ID

Please upload a government-issued photo ID that meets the following criteria:

Clearly shows your face, name, and date of birth.
Ensure the image is free from reflections and blurriness.
All four sides of the ID must be visible.

Why We Request a Photo ID

We prioritise your safety and ensure compliance with medical regulations. Our prescribing team requires a government-issued photo ID to:

Verify your identity.
Ensure that all information you have provided matches the details on your ID.

Your information is handled with the utmost confidentiality and security

Upload ID

You have chosen to upload your documents at a later time. A confirmation email will be sent to you shortly with instructions for uploading.

Please note, your order will be placed on hold until the required documents are uploaded. Once the documents are provided, we will proceed with processing your order.