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?
(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).

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 or GUM clinic with Genital Herpes (HSV-1 or HSV-2)?

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

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

Are you breast feeding or pregnant or possibly pregnant?

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

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

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

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.

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

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.