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

Have you been diagnosed with any medical conditions? Yes | No

If Yes Give Details

Have you ever been diagnosed with a mental health illness? Yes | No

If Yes Give Details

Do you suffer from any allergies? Yes | No

If Yes Give Details

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines. Yes | No

If Yes Give Details

Who is this medication for? (If you are requesting for multiple people, please tell us about everyone)

How old is the person who is going to be using this medication? (If you are requesting for multiple people, please tell us everyone’s age)

Please tell us what this medication is being used to treat?

Has the person used this medication before? Yes | No

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?

Please tell us the duration of symptoms:

Is the person who this medicine is for, have any other medical conditions? Yes | No

If Yes Give Details

Is the person who this medication for, on any other medicines? Yes | No

If Yes Give Details

Do you confirm that you will follow hygiene measures to prevent reinfections e.g. Washing hands, cleaning bed sheets etc

Please provide any further information that you think will help our prescriber when reviewing this request for medication. (optional)

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?

To continue, please provide your GP's surgery address below.

Product

Ovex Tablets Family Pack - Threadworm Treatment£9.99