Assessment

Are you a female? (at birth)

Are you between 18-65 years old?

Have you previously been diagnosed with a Urinary Tract Infection (UTI) by a health professional?

Are you requesting medication to treat a current episode of UTI?

Which of the following symptoms are you experiencing?

If other, please provide more information below.

How long have you had your current symptoms for?

Have you suffered from an episode of UTI in the last 6 months?

Have you suffered from 3 or more UTI's in the last 12 months?

Have you been prescribed antibiotics for a UTI in the last 28 days?

Does your urine appear to be dark brown or red?

Are you experiencing lower back pain?

Are you experiencing any nausea and vomiting?

Are you experiencing and fever / high temperature?

Have you ever been required to attend hospital due to a UTI spreading to your kidneys?

Are you experiencing shaking chills? (rigors)

Are you feeling sleepy, lethargic or confused?

Please enter your date of birth

Do you have any kidney or liver disorders?

Do you have any bladder disorders or are you wearing a urinary catheter?

Do you have any of the following:

• G6PD deficiency
• Porphyria (blood disorder)
• Electrolyte (salt) imbalances
• Vitamin B or folate deficiency
• Diabetes
• Any condition that suppresses your immune system
• Anaemia
• Hereditary galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption
• Lung disease

Are you taking any of the following?

• Anticoagulants (e.g warfarin)
• Immunosuppressant drugs (e.g. Methotrexate, Azathioprine, Ciclosporin)

Are you taking any of the following?

• Rifampicin
• Pyrimethamine and dapsone
• Phenytoin
• Diuretics (e.g. furosemide)
• Bone marrow depressants
• Digoxin
• Procainamide
• Repaglinide
• Spironolactone

Are you currently taking any other medication? (prescribed, over-the-counter, herbal, recreational)

Please list these below

Are you aware symptoms should improve within 24 hours and resolve within 3 days of starting treatment? If symptoms do not resolve within 3 days, you should seek medical help from your GP.

Please note

• Nitrofurantoin is generally recommended as first line treatment but might not be suitable for all.
• Only one antibiotic can be ordered.
• If you have used Trimethoprim in the last 3 months, it is recommended to use Nitrofurantoin.

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

I understand that my request needs to be reviewed and approved by a prescriber. The request is not guaranteed until the prescriber approves it.