Genital Herpes 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. Please share your birth gender *

Female
Male

Are you pregnant or breastfeeding? *

Please share more details *

2. Have you been diagnosed by a healthcare professional with genital herpes? *

You are required to have an official diagnostic from a healthcare professional in order to use our service.

3. For this service, we can prescribe 5 day treatment such as acciclovir or valaciclovir. We are unable to prescribe longer courses of treatment used for supression. Please confirm you understand, and are happy to proceed? *

I understand and wish to proceed

4. Please share with us if you have any of the following symptoms(Select all that apply) *

Temperature/Fever
Muscle aches
Unable to pass urine or pain
Unable to pass a bowel movement or bleeding from back passage
Being sick
Headaches
None of the above

5. Do you have a kidney condition? *

Please share more details *

6. Are you immunocompromised? (weak immune system) *

Please share more details *

7. Please confirm the lesions you are looking to treat are only on/or around your genital area? *

8. Please confirm your age *

9. Who provided your diagnosis of genital herpes? *

Doctor
Nurse
Myself
Other

You are required to have an official diagnostic from a healthcare professional in order to use our service.

Please share more details *

10. Did you have a blood, swab or urine test to confirm the diagnosis? *

11. If you know, please share the type of herpes you have *

Type 1
Type 2
Type 1 and 2
I dont know

12. Where do you experience herpes flare-ups? *

Genitals
Anus
Urethra
Other

Please share more details *

13. Please share the last time you had a flare-up *

14. Did your symtoms go away completely? *

Please share more details *

15. How often were your outbreaks of genital herpes in the last 12 months? *

More than 6 outbreaks
Less than 6 outbreaks

16. Please share the reason you are requesting treatment *

Due to current outbreak
To treat possible future outbreak
Other

17. When did your symptoms start? *

more than 5 days ago
less than 5 days ago

18. Are new lesions still showing? *

19. Please upload a picture of the lesions

Click or drag a file to this area to upload.

20. Please share the treatment you would like to receive? *

acciclovir
valaciclovir
instillagel
other

Please share more details *

21. Do you have any other medication conditions? *

Please share more details *

22. Are you currently using any treatments for genital herpes? *

Please share more details *

23. Have you been prescribed treatment for genital herpes before? *

Please share more details *

24. Do you take any other medication (over the counter, recreational/prescription drugs) *

Please share more details *

25. Do you have any allergies *

Please share more details *

26. Please confirm all the information shared is true *

Yes I can confirm I answered all questions with complete honesty

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Genital Herpes