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?
If you are of child bearing potential, are you using effective contraception?
Have you been diagnosed by your GP or GUM clinic with Genital Warts?
Are you experiencing any of the following?
Do you have an allergy (hypersensitivity) to medicines containing imiquimod or podophyllotoxin?
Are you breastfeeding 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 it is best practice to maintain genital hygiene and avoid sexual contact whilst on treatment, but if you do have sexual contact, please wear a condom?
Do you understand that you should return to your GP or GUM clinic for an examination of your genital warts if they do not improve after 4 weeks of treatment with podophyllotoxin (Warticon) or 16 weeks of treatment with imiquimod (Aldara)?
Do you agree to the following?