UTI (Urinary Tract Infection)

Different parts of your urinary tract, including your bladder (cystitis), urethra (urethritis), or kidneys (kidney infection) can be affected by urinary tract infections (UTIs).

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

Note: You may be contacted by our clinician by phone to discuss your medication request. If we cannot reach you, we will endeavour to call you back / leave a message on how you can reach us. Missing information could affect the approval or delivery of your order.

About your condition and treatment

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.

Are you male or female?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

What is your D.O.B (dd/mm/yyyy)

The Agreement

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

Have you ever previously been diagnosed with cystitis or a urinary tract infection by a GP or other healthcare professional?

Are you currently experiencing symptoms of a Urinary tract infection?

Have you had a previous episode of a urinary traction infection in the last 4 weeks?

In the last 12 months have you experienced a urinary tract infection on more than 3 separate occasions?

Have you ever previously had a urinary tract infection which has not been treated successfully by the first course of antibiotics you received?

Have you ever been previously informed that your urinary tract infection is resistant to an antibiotic?

Are you currently experiencing any of the following symptoms
- Blood in your stools or urine
- Unintentional weight loss
- Night sweats
- Fever
- Pain when passing urine
- Genital discharge

Have you ever previously been informed that you have any form of Kidney disease or reduced kidney function?

Have you ever previously been diagnosed with any other medical conditions?

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Is there any other information you would like to share with our prescribing team?

Risk Assessment

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

Do you agree to the following?
- 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

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UTI (Urinary Tract Infection)

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