Simple Online Pharmacy

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1Medication Safety Check

What was your sex registered at birth? (i.e. your biological sex) *

Are you seeking treatment for anything other than Bacterial Vaginosis? *

NoYes

What symptoms of BV are you experiencing? *

Thin grey/white dischargeFishy-smelling dischargeNeither of these

Are you experiencing any of the following warning symptoms? *

Are you aware of any allergies you have to any medications or substances? *

NoYes

Please provide more information below. *

Are you taking any of the following medications? *

Other than those listed above, do you currently take any prescription medication, alternative medication or recreational drugs? *

NoYes

Please provide more information below. *

Are you currently pregnant, breastfeeding or planning to become pregnant? *

NoYes

Please provide further information below: *

Do you currently have any abdominal pain? *

NoYes

Please provide more information below. *

Are you currently experiencing any abnormal bleeding from your vagina? *

NoYes

Please provide more information below. *

Have you had any gynaecological examinations or procedures recently? *

NoYes

Please provide more information below. *

Do you currently have a contraceptive coil fitted? *

NoYes

Please provide more information below. *

Have you been diagnosed with Pelvic Inflammatory Disease? *

NoYes

Please provide more information below. *

Have you currently or recently had an STI (Sexually Transmitted Infection)? *

NoYes

If yes, please provide more information: *

Do you have any Inflammatory bowel disease (IBD) or history of antibiotic associated colitis? *

NoYes

Do you have any impairment of your liver? *

NoYes

Do you have a condition known as Cockayne Syndrome? *

NoYes

Do you have any other health conditions or problems? *

NoYes

Please provide more information below. *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide information below: *

2Confirmations & Acknowledgments

Please tick to confirm that you aware that you should not drink alcohol while you are taking Metronidazole and for 48 hours after finishing your course. Drinking alcohol while using Metronidazole might cause unpleasant side effects, such as vomiting, stomach pain, hot flushes, and headache. *

Confirm

I understand I must abstain from sexual activity until after completion of a course of vaginally administered treatment - as this could affect treatment success and alter the effectiveness of latex condoms/diaphragms making them less effective. *

Confirm

If you are using Dalacin Cream - if you experience any diarrhoea during treatment, please stop using it and see your doctor. Please tick the box to confirm that you understand. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf?

NoYes

Please enter your postcode to display your local GP's

Please enter your GP’s name and surgery address. Please also enter their email address and fax number, if you know it.

You can find your GP surgery information details below

Please enter your GP surgery name *

Please enter your GP surgery address and post code *

Please enter your GP surgery email

Please enter your name: *

Please enter the address registered with your GP: *

Please enter your date of birth: *

I confirm I am over 18 years old.
I confirm this treatment is for me, and I consent to this treatment.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
I agree to the Simple Online Pharmacy terms and conditions. *

Confirm

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

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Assessment Progress

NHS Prescriptions made Simple

Assessment

1Medication Safety Check

2Confirmations & Acknowledgments