Cold Sore prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Treatment we prescribe is Aciclovir 200mg, 25 tabs *

2. I have been diagnosed with a cold sore by a GP/health care professional *

3. Please confirm why you are seeking cold sore medication *

Please confirm if you have any of the following (select all that apply) *

4. Please share the location of your cold sore? *

Please provide more details *

5. Will you be pregnant, trying to conceive or breastfeeding during the time you will be taking this treatment? (female only) *

6. Please confirm if you have any of the following conditions mentioned below? *

Please share more information with us *

7. Aside from what has been shared already, please confirm if you have had any previous medical illness or conditions or surgeries? *

Please share more information with us *

8. Please share if you are currently taking any prescription or over-the-counter medications, or are currently using recreational drugs? *

Please share more information with us *

9. Do you currently have any allergies? *

Please share more information with us *

10. Please confirm that you understand that to help reduce the frequency of cold sore outbreaks you can use sunscreen or sunblock for this. *

11. Would you like to share any further information with us? *

Type in additional information here *

I can confirm that I have answered all the questions honestly and to the best of my knowledge. This treatment is just for my own self use. There are side effects with treatments, and I understand these. If I would like to know about alternative treatment options, I can book a video appointment and discuss with a Dronline GP.

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Cold Sore