| 1 | Are you pregnant, breastfeeding or trying to become pregnant?
You must answer this question. You must answer this question. | |
| 2 | Have you been diagnosed with blood pressure?
You must answer this question. You must answer this question. | |
| 3 | What is your latest Blood Pressure reading?
You must answer this question. You must answer this question. | |
| 4 | Have you used the medicine you are going to request before (Name of medication and dose)?
You must answer this question. You must answer this question. | |
| 5 | Have you been diagnosed with any of the following conditions?
- Heart block or heart failure
- Breathing/lung problems (such as asthma or COPD)
- Phaeochromocytoma (tumour of adrenal gland)
- Peripheral arterial disease (narrowing of blood vessels in the arms or legs)
- Renal artery stenosis (narrowing of the blood vessels leading to the kidneys)
You must answer this question. You must answer this question. | |
| 6 | Can you confirm that the main reason you take this medication is to control your blood pressure?
You must answer this question. You must answer this question. | |
| 7 | Are you allergic to any medicines or other substances?
You must answer this question. You must answer this question. | |
| 8 | Do you have any liver or kidney problems?
You must answer this question. You must answer this question. | |
| 9 | Have you currently or have you ever been diagnosed with any mental health conditions?
You must answer this question. You must answer this question. | |
| 10 | Are you attending regular (at least yearly) blood tests at your GP surgery to monitor your blood pressure medication (e.g. to check your kidney function)?
You must answer this question. You must answer this question. | |
| 11 | Have you ever had a heart condition or stroke?
You must answer this question. You must answer this question. | |
| 12 | Is your medication currently causing you any side effects
You must answer this question. You must answer this question. | |
| 13 | 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
- You will inform your own GP of this purchase if appropriate
- You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions
You must answer this question. You must answer this question. | |
| 14 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
You must answer this question. You must answer this question. | |
