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Acid Reflux Treatment Questionnaires

Acid Reflux Consultation

You
Medical

Your details

Please provide us with accurate details as our prescriber might need to access your GP record and you are consented to access your Summary Care Record (SCR). This is necessary for the safe and best treatment of your conditions.

First Name

Last Name

Date of birth

Address

Post Code

Is the shipping address the same as above?

Yes

No

What is your shipping address?

Email

Mobile

This service to supply acid reflux medication is ONLY for occasional use!

If you require treatment more than 4 times per week on a regular basis you should contact with your regular GP.

Our clinician will not issue acid reflux medications for patients aged 55 years or over.

Are you aged 55 or over with new or recently changed symptoms?

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

Are you experiencing acid reflux at least twice a week? Symptoms include:

Heartburn - a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours

Chest pain, especially after bending over, lying down or eating

Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat

Feeling of food "sticking" in the middle of the chest or throat

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

Are you experiencing any of the following?

difficulty swallowing

unintentional weight loss

abdominal swelling

persistent vomiting

severe/persistent diarrhoea

vomiting blood

blood in your stools or black, tarry stools

have iron deficiency anaemia

severe liver problems

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

Are you allergic to medicines containing proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

Do you have any of the following conditions:

Osteoporosis

Liver problems

Gastric cancer

Low magnesium in the blood (Hypomagnesaemia)

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

Are you taking any other medication including over-the-counter and homeopathic medicines.

Yes

No

Please provide the name of the medications:

Are you pregnant or planning for a baby or breastfeeding?

Yes

No

Unable to proceed, please consult your GP.

Exit consultation

We strongly advise that you inform your GP of any treatment you receive. Would you like us to inform them on your behalf?

Yes

No

Please give us your GP surgery name and address, phone number and email address:

Consent

I fully understand the questions asked and have answered honestly and truthfully.

I understand that acid reflux treatment supplied through this service can only be used for the short-treatment of heartburn and /or acid indigestion for a maximum of 28 days.

I understand that if no relief after 14 days or symptoms persist after 28 days of treatment, I shall contact GP for further diagnosis/treatment.

I fully understand the side effects of the treatments, their effectiveness & am happy to continue with my request.

I will read the patient information leaflet supplied with the medication.

I confirm & agree that any treatment prescribed for me is for my personal use only.

I consent to have OnlineChemist store my submitted information so they can respond to my inquiry.

I consent to the OnlineChemist accessing my NHS summary care record (SCR) to process my treatment, if needed.

I have read and agree to the Terms and Conditions and Privacy Policy

Prescription (official use only)

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Online Chemist in Gorleston, an NHS online pharmacy and travel vaccine clinic

Online Chemist
82 Middleton Road
Gorleston
Great Yarmouth
Norfolk, NR31 7AH
Phone: 01493 600610
Email: info@onlinechemistuk.net

Superintendent Pharmacist:
Obaidullah Zaman
BPharm, MPharm, PGDip (Pharmacy), MRPharmS, IP
GPhC Reg. Number: 2083409

Pharmacy Premises GPhC Reg. Number: 9011159

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NHS online pharmacy Gorleston Great Yarmouth Norfolk

OPENING HOURS

Monday 09:00 – 17:00
Tuesday 09:00 – 17:00
Wednesday 09:00 – 17:00
Thursday 09:00 – 17:00
Friday 09:00 – 17:00
Saturday Closed
Sunday Closed

Click here for driving directions

Online Chemist is a trading name of Nomaz Limited.
Registered in England – 11349276.

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