Rxpress

To help us direct you to the appropriate clinician please select the reason for your consultation request:
Acid RefluxAllergic RhinitisAllergies/HayfeverViral Infection/HerpesEar InfectionEye InfectionHaemorrhoidsHivesMigraines/HeadachePain ManagementSore ThroatUrinary Tract InfectionUrinary IncontinenceOther Medical Issue

Date of Birth (DD/MM/YYYY):

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Full Name:

Home Address:

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Telephone:

Name & Address of GP:

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Consultation Questions

Who is the treatment for?

What are the symptoms?

How long have the symptoms been present?

What actions have already been taken?

Are you taking any other medication (prescription, OTC or herbal)?

Medical History

Do you have any allergies?
YesNo

If yes, please provide details:

Do you have any relevant past or current medical conditions?
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If yes, please provide details:

Have you had this condition before?
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Have you tried any treatment already? If yes, what was it and did it help?

Are you pregnant, planning pregnancy, or breastfeeding?
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Do we have permission to access your medical records?
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