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, nurse or pharmacist with cold sores (herpes labialis)?
Do you have any of the following symptoms:
Do you have an allergy (hypersensitivity) to medicines containing Aciclovir or Valciclovir or Famacilovir or Penciclovir?
Are you pregnant, breast feeding or possibly pregnant?
Have you been diagnosed with any of the following conditions?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
Do you understand that outbreak treatment should be initiated at the earliest symptom of a cold sore eg tingling, itching or burning sensation?
Do you understand that if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?
Do you agree to the following?