1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Details & PaymentWe will now ask you some questions to assess your suitability for a prescriptionJust before you start, it is important that you read this:Welcome to our online clinic. This questionnaire forms the basis of today's consultation. We need you to be honest with your answers so we can prescribe medication safely and give you the right advice. If you forget to tell us something or give inaccurate information, this may result in a drug being prescribed that harms rather than helps you. It's important that you tell us about any medication you are already taking when we ask for this.Antibiotic treatment can cause your body to develop resistance. It is important you only order this antibiotic if you know you or your partner has chlamydia.I agree to answer questions honestly and fullyYesNo Your ConditionI am seeking treatment as I have*Been diagnosed by my GPOtherWhy are you seeking treatment? Please tell us why you think you have cystitis*What symptoms do you have?* Discomfort or a burning sensation on passing urine Discomfort in your lower abdomen Fever, high temperature or uncontrollable shaking Sudden urges to pass urine Urinating more frequently Constant irritation or itching of the vagina New or abnormal vaginal discharge Current episode of cystitis for more than two days Pain or severe discomfort around your mid back or sideYour HealthHave you ever been diagnosed with liver or kidney conditions?*NoYesPlease provide information*Have you previously been admitted to hospital due to a cystitis infection spreading to your kidneys?*NoYesPlease provide information*Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?*NoYesPlease provide information*Do you have any known allergies?*NoYesPlease provide information*Are you pregnant, planning to become pregnant or breastfeeding?*NoYesN/APlease provide information*ConsentI agree to the site's terms and conditions. I confirm I am over 18 years old. The medicine ordered is for my sole use only. I will read the patient information leaflet supplied with the medicine or obtain it from the website; I will especially take note of the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.NoYes I Agree Choice of Medication*Trimethoprim x 6 (3 day course) - £9.50Prescription Charge £ 5.00Total £ 0.00 Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.