top of page
Ingleton Pharmacy Logo.png

Disclaimer - Threadworms Consultation

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

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

Is the person using this medicine pregnant or breast feeding?

If Yes Give Details

Does the person(s) have itching around the anus or vagina
Does the person(s) have visible worms or stools around the anus?

If Yes Give Details

If Yes Give Details

Do you confirm that you will follow hygiene measures to prevent reinfections e.g. Washing hands, cleaning bed sheets etc
I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform my own regular doctor of
Would you like us to inform your GP?
Product
bottom of page