About you
Are you aged between 18 and 60?
We are unable to supply you the product. Please consult your GP.
Please complete this question.
Are you pregnant or breast feeding, or intending either whilst on this medication?
We are unable to supply you the product. Please consult your GP.
Please complete this question.
Are you allergic (hypersensitive) to any of the following:
- A topical antifungal treatment (such as clotrimazole or miconazole)
- Antifungal tablet (such as fluconazole)
- Cetostearyl alcohol
We are unable to supply you the product. Please consult your GP.
Please complete this question.
Other Medical Conditions
Are you experiencing any of the following:
For women only:
- abnormal or irregular vaginal bleeding or a blood-stained discharge
- vulval or vaginal ulcers, blisters or sores
- lower abdominal pain or pain when urinating
- fever or chills
- nausea or vomiting
- diarrhoea
- foul smelling vaginal discharge
We are unable to supply you the product. Please consult your GP.
Please complete this question.
Do you have any of the following:
- diabetes
- weakened immune system
We are unable to supply you the product. Please consult your GP.
Please complete this question.
Agreement:
You confirm that you:
- Have not had more than two infections of thrush in the last 6 months
- Are not allergic (hypersensitive) to clotrimazole, other antifungals and thrush treatments or any other ingredient
- Do not have a history of a sexually transmitted disease or exposure to a partner with sexually transmitted disease
Please confirm that you understand.
Please complete this question.
Do you agree with the below:
- The treatment is for your own use
- You will contact us and your GP should you experience any side effects from the treatment, if your condition changes or if your medical circumstances change.
- You will read the patient information leaflet supplied with your medication
- You have completed this questionnaire yourself and fully understand all the information
- Your responses are honest and accurate, and you understand that this is necessary for a safe medical assessment
- You agree to the terms & conditions, privacy policy, & data sharing policy
Please confirm that you understand.
Please complete this question.
COMPLETE OUR 2 MINUTE QUESTIONNAIRE
To find a treatment suitable for you, we just need you to answer a few questions.
Confidential & Secure
- We will review your details in complete confidence
- Your medication will be delivered in plain unlabelled packaging
- Appears on your statement as "Pharma"
- All data is securely encrypted with 256-bit SSL