Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What symptoms do you currently have? (Tick all that apply) *

Blocked or congested nose

Thick yellow/green nasal discharge

Pain or pressure around the cheeks or forehead

Tooth pain (especially upper jaw)

Fever

Reduced or lost sense of smell

Headache

Cough

(These symptoms may indicate complications and require urgent face-to-face care.) *

Have you had any of the following? (Tick all that apply)

Swelling or redness around the eyes or eyelids

Severe facial pain or swelling

High fever not controlled by pain relief

Visual changes (e.g. blurred or double vision)

Confusion, drowsiness, or difficulty staying alert

Neck stiffness or severe headache

None of the above

Do you have any of the following? (Tick any that apply) *

Asthma

Nasal polyps

Immune system condition (e.g. on immunosuppressants)

Chronic sinusitis (longer than 12 weeks)

None of the above

Consent & Declaration *

I confirm that the information I’ve provided is accurate and complete.

I understand that antibiotics will only be prescribed if clinically appropriate.

I agree to seek urgent medical attention if advised or if symptoms worsen.

I consent to treatment if appropriate.