Please tell us what symptoms you are suffering from. Tick all the symptoms that apply to you:

small blisters that burst to leave red, open sores around your genitals, anus, thighs or bottom
tingling, burning or itching around your genitals
pain when you pee
in women, vaginal discharge that's not usual for you
severe headaches with vomiting
not being able to pass any urine at all

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.

For how long have you been suffering from this?

less than 3 months
3 to 6 months
longer than 6 months

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.

How often have you experienced herpes outbreaks in the past year?

Less than 6 times
More than 6 times

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 taken any medication for herpes in the past?

Yes No

Which medication did you take, and did it help to clear up your symptoms?

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 ever been tested for herpes?

Yes No

If you have never had a test for herpes it is important that you do, to confirm that your symptoms are caused by herpes. For a test you can see your GP, sexual health clinic or order a home test kit online.

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 or planning to get pregnant or start 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.

Does any of the following apply to you?

Yes No

you are HIV positive;
you have any condition affecting your kidneys, urinary system or liver;
you have problems with your body’s immune system;
you have any other health conditions 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 taking any of the following?

Yes No

Raloxifene (used to prevent and treat osteoporosis);
Probenecid (used to treat gout) ;
any other medication that can affect your kidneys;

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 taking any other medication not mentioned above?

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 allergic to famciclovir or penciclovir or to any of the other ingredients of this medicine?

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 agree to the following?

Yes No

If you are taking Famciclovir to treat or to suppress genital herpes you should still practise safe sex, including the use of condoms. This is important to prevent you passing the infection on to others. You should not have sex if you have genital sores or blisters.;
Famciclovir can cause dizziness, drowsiness or confusion. Do not drive or use machines if you have any of these symptoms while taking Famciclovir.;

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.

Please tick the boxes to confirm the following:

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

You must accept the terms and conditions to continue!

Medical Assessment