Female Patients Form 2

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Female - Bacterial Vaginosis treatment

Put your details

Pharmacy Name*

Pharmacy Location*

Pharmacy EirCode*

Have you been diagnosed with having Bacterial vaginosis in the past?

YES NO

What medication were you prescribed?

ORAL - Oral treatment is in the form of pills TOPICAL/VAGINAL - topical treatment is in the form of ointment

What form of medication are you requesting?

ORAL TOPICAL/VAGINAL

Are you currently pregnant?

YES NO

In the last 12 month period, how many times have you received treatment for Bacterial Vaginosis?

0 1-2 3 OR MORE If YES, give as many details as possible about the treatment you had:

In the last 12 month period, have you engaged in sexual intercourse with a new partner or have you had more than one sexual partner?

YES NO

Do you currently have any form of contraceptive device fitted in your uterus?

YES NO If YES, please specify which contraceptive device, for how many months:

Have you undergone any gynaecological procedures in the last 12 months?

NO If YES, please specify:

Have you ever been diagnosed with Pelvic Inflammatory Disease (PID)?

NO If YES, please specify:

Do you currently suffer from persistent heavy periods?

YES NO

Have you been tested for an STI (Sexually Transmitted Infection) within the last 12 months?

NO If YES, please specify what infection was diagnosed:

Have you been diagnosed with any neurological conditions?

NO If YES, please specify:

Have you been diagnosed with any kidney or liver disease?

NO If YES, please specify:

Are you currently breastfeeding ?

NO YES, I AM, please specify:

Do you plan on becoming pregnant in the next few months?

NO YES

Do you currently take any prescription medications?

NO If YES, please specify:

Do you currently take recreational / illegal drugs?

NO If YES, please specify:

Do you currently take any non-prescribed medications, vitamins or herbal medications?

NO If YES, please specify:

Do you have any additional Medical information, or are you currently taking any other form of medication, which you feel would be important for our Doctor to know about?

YES If YES, please specify:

Do you have any known allergies to any medication?

NO If YES, please specify more information about the allergies you have to medicines or tablets:

What sex were you when you were born?

FEMALE MALE

What is your height (enter as centimeters)?

What is your current weight (enter as kg)?

Are you currently or have you been a smoker in the past?

NO If YES, I HAVE, please specify (How many do you smoke per day):

What age are you?

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

Medications have the potential to interact with a variety of prescribed, non-prescribed and recreational/illegal drugs. Please answer truthfully and to the best of your knowledge. Do you confirm that you have understood all of this form and read it fully and that your answers are completely correct and true, to the best of your knowledge?

YES, I fully understood and my answers are correct and true, to the best of my knowledge. NO, I do not understand and I will require additional assistance.

Complete the prescription form below. If the doctor determines that an prescription is not appropriate for your case, you will be refunded.

EXPRESS SickCert: Prescription within 24hrs sent via email. 29.99 EUR

*This will be reviewed and signed by an Irish doctor and is emailed to you within 24 hours.

RECOMMENDED: Prescription will be prioritised in the queue and sent via email. 24.99 EUR

*This will be reviewed and signed by an Irish doctor, sent via email and your request will be at the top of the request queue.

EMAIL: Prescription will be sent via email within 2-3 working days 19.99 EUR

*This will be reviewed and signed by an Irish doctor and sent via email, usually delivered within 2-3 working days.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).

I CONFIRM I DO NOT CONFIRM

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Female Patients Form 2

Female - Bacterial Vaginosis treatment

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