Hayfever Consultation

Are you currently experiencing any of the following symptoms? *

Please select all options that apply (You can select more than one option)

Sneezing Itchy or blocked nose Itchy, red, and/or watery eyes None of the above

Regarding any medical conditions, do any of the following apply? *

Please select all options that apply (You can select more than one option)

Heart problems including an irregular or fast heartbeat or angina Epilepsy Kidney or Liver problems None of the above

Do you currently have any of the following? *

An active or untreated local or systemic fungal, bacterial, or viral infection? Currently taking systemic corticosteroid treatment, such as Prednisolone Have an untreated localised infection around/within the nose, for example, herpes simplex None of the Above

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

Yes No

Please provide more details of all medication you are taking

Are you breastfeeding, pregnant, or possibly pregnant? *

If you are Male, please select No

Yes No

Have you ever had an allergic reaction to antihistamines, mometasone or beconase nasal spray, hayfever relief eyedrops, Or have any other allergies we should be aware of, including lactose intolerance? *

Yes No

Please provide more details on ALL of your allergies

Is there any other relevant medical information that would help our prescribers to prescribe this medication safely to you? *

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 requesting fexofenadine, I confirm I have previously tried other antihistamines without success
I have 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 understand if my symptoms do not improve after 2 weeks after starting this treatment I should stop taking this medicine
I understand I should not take indigestion remedies or ulipristal (also known as EllaOne or Esmya) 2 hours before or after you take this medicine
I understand that this medication may cause drowsiness which may affect my ability to drive or operate machinery. I agree if this happens, I will not drive or use tools or machines. I understand that by drinking alcohol whilst on this medication may make me feel more drowsy
I will not take grapefruit, apple or orange juice with this medication as it can increase the risks of side effects

I agree to all of the above statements