Please confirm the following:*

I am 18 years old or above.

I am using this service on my own behalf and of my own free will, and any treatment or advice is for my sole use only.

I will inform my GP of any treatment I have received.

I understand my consultation will not be passed to the YourPharmacy online clinical team until I have purchased my preferred treatment.

I agree to YourPharmacy’s Terms & Conditions and Privacy Policy.

I confirm and understand all of the above

Name*

First Last

Date of birth*

Day

Month

Year

What is your sex?*

Phone*

Email*

Street Address*

City*

County / State / Region

Post Code*

Country*

Select Weight*

Select Height*

Please enter your current weight (kg)*

Please enter your current height (cm)*

Please enter your current weight (Stones and Pounds)*

Please enter your current height (Feet and Inches)*

Are you currently pregnant, trying to conceive or breastfeeding?*

I am pregnant

I am breastfeeding

I am trying to conceive

None of the above

Do you have or have you ever had an eating disorder such as anorexia or bulimia?*

Yes

What is your ethnicity (required for BMI purposes )*

Are you currently using any weight loss medication?*

Yes

Are you currently taking any prescription medications?*

Yes

Please let us know what prescription medications you are taking.*

Do you have any medical conditions?**

Yes

Please let us know your medical conditions.*

Do you have any allergies that you are aware of?*

Yes

Please let us know what allergies you have.*

Do you consent for YourPharmacy to check NSCR to confirm your identity and your suitability for this treatment?*

Yes

Would you like us to send this consultation to your GP?*

Yes

What's the name and address of your GP's practice?*

Please write the full name of your GP and mention the full address

Pharmacy First Sore Throat Consultation

Patient Acknowledgement

By completing this consultation you agree to YourPharmacy's Terms and Conditions and Privacy Policy.

Important Information

You must not complete this consultation if you are experiencing any of the following

If any of these apply you must call 999 immediately

Difficulty breathing or swallowing.

Breathing that sounds abnormal or high-pitched.

A muffled or hoarse voice drooling.

If you have any of these other conditions you must not wait for a response from us and contact your GP or 111 immediately.

A weakened immune system

You are not producing as much urine as usual.

Feeling to unwell to care for yourself, for example simple tasks like washing or making food.

A fever with feeling generally weak, dizzy or excessively tired

I agree to the terms and I confirm none of the listed conditions apply to me

Name(Required)

These must match your NHS file

First Last

Date of Birth(Required)

What is your gender(Required)

This much match your NHS file

NHS number (if known)

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

How long have you had as sore throat?(Required)

Have you felt feverish in the past 24 hours?(Required)

Yes

Have you checked your temperature recently?(Required)

Yes

Please enter the reading below (°C)

Do you have a cough?(Required)

Yes

How long have you had the cough?(Required)

Do you have a blocked or runny nose?(Required)

Yes

Do you have a rash or does your skin feel rough, like sandpaper?(Required)

Yes

I'm not sure

Upload a Photo(Required)

Tips for taking a good photo

Make sure you have adequate lighting

Make sure the subject is clear and in focus.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Do you have any allergies?(Required)

Yes

Please specify more details(Required)

Please list any allergies and the reactions you have.

Do you have a condition or use any medications that cause you to have a weakened immune system?(Required)

For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV.

Yes

What is the cause of your weakened immune system?(Required)

Please select the statement that best suits your circumstance.(Required)

I am pregnant

I'm trying to conceive

I am breastfeeding

None of the above

One of our pharmacists may need to contact you whilst they are processing your consultation, when would be the best time to contact you?

We can’t guarantee a time and will only contact you during opening hours, (Mon - Fri, 9am to 5pm)

Patient Agreement

By completing this consultation you agree to the following:

You answered all the questions correctly and to the best of your ability

You consent to YourPharmacy contacting you via phone or email to ensure the best possible care

You confirm you do not NEED URGENT medical attention, if so ring 999.

I agree

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