Medical Assessment for Genital Herpes

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you aged between 18 and 65?

Yes

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)?

Yes

We are unable to treat you if you have not been diagnosed. Please consult your GP or your local GUM clinic.
If you are looking to treat Cold Sores (HSV-1), click here

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Your 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

Yes

Consult your GP urgently. These symptoms indicate the possibility of a more serious illness.

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Your Health

Are you breast feeding or pregnant or possibly pregnant?

Yes

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

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

Yes

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

Yes

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

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Your Medication

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

Yes

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

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

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Agreement

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, you start new medication and/or 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 understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

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Do you understand that if your symptoms do not improve after 7 days you must see your doctor?

Yes

If your symptoms persist you may have a more serious illness. Contact our helpline for more information

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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.

Yes

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

Please complete this question.

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

Yes

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

Please complete this question.

Medical Assessment for Genital Herpes

To help us supply you with the most suitable treatment, please complete this online consultation.

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