Chlamydia Consultation

What is the reason for requesting this treatment? *

I have had a positive test for Chlamydia in the last week A sexual partner has informed me they have Chlamydia None of the above

Please select any of the following symptoms you are currently experiencing? *

You can select multiple options if required

Pain or burning when passing urine Vaginal/Penile discharge Pain in the lower abdomen Abdominal pain during sex Pain or discharge from your anus/rectum Unexpected or unusual bleeding Temperature/fever above 38 degrees celcius None of the above

Are you pregnant, breast-feeding or planning to become pregnant whilst taking treatment? *

If you are Male, please select No

Yes No

Have you taken antibiotic treatment for Chlamydia in the last 2 months? *

Yes No

Did the treatment clear your symptoms? AND, since completing your treatment, have you had sexual contact with someone who has chlamydia?

Have you ever had an allergic reaction to doxycycline? Or do you have any other allergies we should be aware of? *

Yes No

Please provide more details on all allergies you have

Regarding your medical conditions, do you currently have or suffer from any of the following? *

You can select multiple options if required

Liver disease Kidney disease Systemic lupus erythematosus (SLE) Myasthenia gravis HIV None of the above

Are you currently taking or have recently finished taking (in the last month) any medication, whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide an update list of all medications whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs that you are taking or have recently stopped taking

Is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

Before you continue

Please read the following statements:

I confirm these questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from Pharmacy
I confirm I will take the medication as prescribed or directed for its intended use and if I am not requesting the starting dose for that medication, I have taken the medication previously on that dose and without any side effects
I have read or will read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
I should avoid sexual contact for 7 days following treatment
I should tell any sexual partner(s) in the last 6 months that they may have caught chlamydia and so should be tested themselves
I confirm I do NOT have a temperature above 38 degrees Celsius. This may indicate a serious infection. and you should contact your GP or a clinic urgently for an in-person assessment

I agree to all of the above statements