Why do you require Aciclovir/Valaciclovir?

treatment of cold sore (herpes labialis)
suppression of cold sore (herpes labialis)

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 aged between 18 and 65?

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.

Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?

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.

How many times per year do you suffer from herpes labialis (cold sore)?

1 to 2 times per year
2 to 4 times per year
4 to 6 times per year
more than 6 times per year

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 have any of the following symptoms?

Yes No

mouth ulcers /lumps lasting more than 3 weeks;
painful red and white patches on the inside of the mouth;
fluid filled blisters/crusts on the lips;

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.

Do you have an allergy (hypersensitivity) to Aciclovir, Valaciclovir or to any of its ingredients (such as lactose)?

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 pregnant or breastfeeding or planning during its course?

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

severe breathing difficulties;
any other chronic condition that we should know about;
nervous system abnormalities;
liver problems;
kidney problems;
any condition affecting the immune system (e.g. HIV, cancer);

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

probenecid (to treat gout);
cimetidine (for stomach acid);
mycophenolate mofetil (used in transplant patients);
theophylline (asthma);
zidovudine (HIV treatment);

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 currently taking any other medication (including over the counter, prescription or recreational drugs)?

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.

Do you understand that treatment should be initiated at the earliest symptom of a cold sore e.g. tingling, itching or burning sensation and if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?

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

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;
the treatment is solely for your own use and you will use it only for the purpose of cold sores (herpes labialis) and not for any other condition;
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