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Disclaimer - Acid Reflux Consultation Form

This questionnaire forms the basis of your consultation today. We require you to be truthful and transparent with your answers including any current medication you are on, your medical history and any other information our prescribers should be made aware of. This allows our prescribers to provide you with the best advice and choice of medication suited to your need. Please read all the medical information before choosing your preferred treatment.
 

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?
What is your Date of Birth?
Day
Month
Year

If Yes Give Details

If Yes Give Details

If Yes Give Details


If Yes Give Details

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Healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable. Do you understand this?
Acid reflux treatment from this service to treat acid reflux can only be used for a maximum of 28 days. Do you understand this?
If you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment. Do you understand this?
Would you like us to inform your GP?
10mg
7 Capsules: £1.99
14 Capsules: £3.49
28 Capsules: £7.99
20mg
7 Capsules: £2.49
14 Capsules: £4.49
28 Capsules: £8.49
Product
Omeprazole Capsules
Omeprazole Capsules£1.99
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