What symptoms are you suffering from? Tick all the symptoms that apply to you:

bright red blood after you poo
an itchy anus
feeling like you still need to poo after going to the toilet
slimy mucus in your underwear or on toilet paper after wiping your bottom
pain around your anus
blood in the stools or vomit
difficulty swallowing
pain in the stomach or gut that is always present
tiredness and lack of energy

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you been previously diagnosed with piles?

Yes No

when did you last consult your GP about this?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you aware that people aged over 55 should undergo NHS bowel screening? You can find out more about screening here:https://www.nhs.uk/conditions/bowel-cancer-screening/#when-its-offered

Yes No

Select atleast one option

Do you suffer from any of the following?

Yes No

you experience symptoms for the first time, and you are over 40 years of age;
weight loss for no apparent reason;
rectal bleeding (especially if the blood is darker in colour);
iron deficiency (anaemia);
gastric or stomach ulcers;
a swelling or lump in your stomach or bottom;
a complete inability to pass stools (intestinal obstruction);

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

problems with kidneys and/or liver;
immune system disorder (such as HIV);
constipation;
viral infection e.g. herpes, shingles, chickenpox;
you have any bacterial or fungal infections of the skin or elsewhere for which you are not receiving treatment.;
any other chronic condition we should know about;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to prednisolone, cinchocaine, hydrocortisone, other local anaesthetics or to any other ingredient of haemorrhoid medicines?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medications (prescription, herbal or over the counter)?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you aware of the following?

Yes No

you should not use Uniroid HC or Scheriproct ointment for more than 7 days;
long-term continuous use of Uniroid HC or Scheriproct ointment can cause increased side effects and thinning of the skin;
you should not cover the area of application with a dressing;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

you answered truthfully to all the questions and you are aware that any incorrect information you provided might present a danger to your health;
you will seek medical attention if you experience any unusual side effects;
if your condition gets worse or does not improve while using this medication you will contact your doctor immediately ;
the treatment is solely for your own use ;
you will read the patient information leaflet supplied with your medication;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

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Medical Assessment