Start Your Cough/Chest Infection Consultation

Please complete this confidential form. Our clinician will review and respond shortly.

Name

First Name

Last Name

Date Of Birth

YYYY

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you have a cough?

How long have you had your cough?

Are you coughing up phlegm (sputum)?

Do you have a wheeze when breathing?

What colour is the phlegm (if any)?

(Clear, Yellow, Green, Blood-stained)

Do you have a fever (over 38°C)?

Do you feel breathless or short of breath?

Are you coughing up blood?

Are you severely short of breath at rest?

Do you feel confused or drowsy?

Do you have a chronic condition (e.g. asthma, COPD, heart disease, diabetes)?

If yes, please detail below

Are you currently pregnant or breastfeeding?

Do you smoke or have you smoked in the past?

Have you taken any treatment already for this infection?

If yes, what have you taken? (e.g. paracetamol, antibiotics)

Are you allergic to penicillin or any other antibiotics?

If yes, please describe the reaction:

Are you registered with a GP?

Name of GP Surgery

Would you like us to contact your GP?

Consent & Declaration

I confirm the information provided is accurate.

I understand that this service is not a substitute for NHS emergency care.

I am over 18 years of age.

I consent to the use of my data for safe prescribing.

⚠️ IMPORTANT:

If you answered YES to:

• Coughing up blood

• Severe breathlessness

• Confusion or drowsiness

Please stop and contact NHS 111 or seek urgent medical attention. You may require in-person assessment for pneumonia or other serious illness.

Start Your Cough/Chest Infection Consultation

I Need A Prescription