Assessment

Have you taken this medication before?

Have you ever been diagnosed by your GP of having alergic rhinitis/hay fever or chronic urticaria (hives lasting 6 weeks or more)

What are your symptoms?

Please provide more information below

Do you have a known allergy to the hay fever treatment you are requesting? NOTE: The following sprays contain steroids: Beconase, Dymista, Avamys & Flixonase.

Are you aware of any side-effects you have experienced from the requested hay fever medication?

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Please enter your date of birth

Are you currently pregnant or breastfeeding or intending to become pregnant or breastfeed whilst taking treatment?

Have you ever been diagnosed with liver or kidney disease?

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Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?

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Do you have any known allergies?

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Do you have any other significant medical conditions that you think we should know about? (e.g. recent or major operations, porphyria, neurological conditions or mental illness etc.)

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Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?

Please give more details

We strongly advise that you inform your GP of any medication you receive.

Would you like us to inform your GP of medication you receive from Rightdose?

Please enter your:

• Full Name
• Date of Birth
• Your registered home address with your GP

Please enter your:

• GP Surgery Name
• GP Surgery Address
• GP Surgery Email
• GP Surgery Contact Number

I confirm:

• I am over 18 years old
• The medicine ordered is for my sole use only
• I take responsibility to inform my own regular doctor of the online assessment or any changes in my circumstances
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages
• I have answered all the questions truthfully
• I agree to the Rightdose online pharmacy privacy policy and terms and conditions