Start Your Ear Infection Consultation

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

Name

First Name

Last Name

Date Of Birth

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Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

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Which ear is affected?

How long have you had symptoms?

Do you have pain in the ear?

Is there discharge from the ear?

Do you feel pressure or fullness in the ear?

Are you experiencing hearing loss in the affected ear?

Do you have a fever?

Is the outer ear tender or painful when touched or moved?

Do you have swelling behind the ear or the ear looks pushed forward?

Do you have pain when opening your jaw or facial swelling?

Have you had recurrent ear infections in the past 3 months?

Have you had recent water exposure (e.g. swimming)?

Do you have any hearing aids or devices in your ears?

Are you immunocompromised or do you have diabetes?

Have you taken any treatment already for this infection?

If yes, please list medications (e.g. paracetamol, ear drops, antibiotics)

Are you allergic to any antibiotics (e.g. penicillin)?

If yes, please describe the reaction

Are you currently pregnant or breastfeeding?

Are you registered with a GP?

GP Surgery Name

Would you like us to notify your GP of this consultation?

Consent & Declaration

I confirm the information I have provided is true and complete.

I understand this is a private medical service and not a replacement for NHS emergency care.

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

I understand that if red flags are identified, I may be advised to seek in-person care.

⚠️ URGENT: If you have swelling behind the ear, confusion, vomiting, or the ear looks pushed forward, please seek urgent medical care.

These may be signs of a serious infection that cannot be treated remotely.

Start Your Ear Infection Consultation

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