Are you pregnant or breastfeeding or trying to become pregnant?Bottom of Form

Do you have any problems with your liver or kidneys?

Do you know what is causing your pain?

Have you used the treatment you are requesting before and did it help with the pain?

Have you seen your GP about your pain?

Are you currently seeing, or have you recently seen, a hospital specialist?

Do any of the following symptoms accompany your pain?

• Redness of the painful area
• Swelling of the painful area
• Bruising
• Weakness
• Broken skin
• Area is painful to touch
• Nausea

Are you currently taking any medication to relieve your pain?

Do you agree to see your GP if:

• Your pain doesn’t improve with treatment
• Your pain worsens with or without treatment
• You’re in severe pain
• Your pain spreads to new areas
• Your pain impacts your quality of life

Do you agree to the following?

• You will read the Patient Information Leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• The treatment is solely for your own use
• You are over the age of 18 and you have entered your own information for our identity verification checks
• You have answered all the above questions accurately and truthfully
• You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health

What is the name of your GP surgery and do you consent to us contacting them about your treatment?