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?
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?
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 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?