To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Male
Female
Transmale (Born a female)
Transfemale (Born a male)




Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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- Blood in your stools or urine
- Unintentional weight loss
- Night sweats
- Fever
- Pain when passing urine
- Genital discharge









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- I am between the ages of 18 and 65
- This treatment is for my use only
- I have the capacity to make decisions about my own healthcare
- I have understood all the questions and have answered this consultation truthfully and completely
- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health
- I will read the patient information leaflet supplied with this medication
- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health
- I have read, understood and agree with our Terms and Conditions