Medical Assessment

Is this medication for your personal use?

Yes No

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.

What symptoms are you suffering from? Please tick all the symptoms that apply to you.

bloodshot eyes
eyes that feel burn or gritty
eyes that produce pus that sticks to lashes
eyes that itch
eyes that water

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

a rare illness called aplastic anaemia;
any problems with your eyesight, or severe eye pain;
swollen eyes and a rash on your face or head;
a cloudy eye;
unusual looking pupils - irregular size, dilated or not reacting to light;
had a recent eye injury, or something in your eye;
recently had conjunctivitis;
dry eye syndrome ;
glaucoma;
had eye surgery or laser treatment in the last 6 months;

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 chloramphenicol or to any other medicines?

Yes No

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 other medication (including prescription, over the counter or herbal medication)?

Yes No

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 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.

Do you agree to the following?

Yes No

if your condition doesn’t improve after 48 hours of using this ointment you will see your GP;
you will contact your GP immediately if you experience any pain in your eyes, sensitivity to light, changes in your vision (like wavy lines or flashing) or intense redness in one or both eyes;

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 have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
you will inform your doctor about any unusual side effects;
the treatment is solely for your own use;
you will not exceed the maximum daily dose of this medication ;
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!