Pain Relief Consultation

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

What is your shipping address?

Mobile

Our clinician will not issue Naproxen or Nefopam for patients over the age of 65. You may continue this consultation and order Paracetamol.

If you need Naproxen and are over the age of 65, please speak to your GP.

Please provide the details of your pain/conditions

Please provide more information about your pain.

Is your pain a result of injury or trauma?

How severe is the pain?

Does your pain affect your quality of life?

Is your pain worsened by any specific triggers? e.g. Exercise, sitting, or walking.

How often do you experience this type of pain?

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

Yes

Please provide the name of the medications:

Do you suffer from liver or kidney disease?

Yes

Have you ever had difficulty peeing?

Yes

Do you suffer from angle closure glucoma?

Yes

Have you been diagnosed with any other medical or mental health conditions?

Yes

Please provide the details of the condition:

Are you pregnant or planning for a baby or breastfeeding?

Yes

Please provide the details of the condition:

Important information about your pain mediation:

You agree to see your GP urgently if: your pain does not improve with this treatment; your pain becomes worse; your pain is spreading to other areas of the body; or your pain is having a significant long-term impact on your quality of life.
For Naproxen/Ibuprofen: You understand naproxen or ibuprofen should be taken with or 30 minutes after food and should not be taken with any other anti-inflammatory pain killers such as aspirin or diclofenac.
For Nefopam: You understand nefopam dose is one or two 30mg tablets up to 3 times a day. If you have taken this tablets for a long time, speck to your doctor if you want to stop taking it.
For Paracetamol: You understand not to take this medication with any other medication containing paracetamol. You should take up to 2 tablets 4 times a day and no more than 8 tablets in a 24 hour period.
You agree to see your GP urgently if you experience any of the following; severe indigestion, heartburn, pains in your stomach, feeling sick or vomiting or diarrhoea – these can be signs of an ulcer or inflammation in the stomach or gut; vomiting blood or dark particles that look like coffee grounds, blood in your poo, or black, tarry-looking poo these could be signs of bleeding and perforation of the stomach or gut; you lose a lot of weight for no reason and have problems swallowing.

I understand

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

Yes

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 fully understand the side effects of the treatments, their effectiveness and alternative options & am happy to continue with my request.
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)

Your details

Our clinician will not issue Naproxen or Nefopam for patients over the age of 65. You may continue this consultation and order Paracetamol.

Important information about your pain mediation:

Consent

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