Start Your Tonsillitis 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

(###)

###

####

Are you registered with a GP?

GP Surgery Name

Would you like us to notify your GP?

Do you have a sore throat or pain when swallowing?

Do you have a fever (temperature over 38°C)?

Have you had swollen or painful glands in your neck?

Have you noticed white spots or pus on your tonsils?

Have your symptoms lasted longer than 7 days?

Have you had tonsillitis more than 3 times in the past year?

Are you having difficulty breathing, or noisy breathing (stridor)?

Are you unable to swallow fluids or saliva?

Do you have a stiff neck or sensitivity to light?

Are you currently pregnant or breastfeeding?

Are you allergic to penicillin or any other antibiotics?

If yes to allergies, please describe the reaction

Please provide any additional information

Consent & Declaration

I confirm the information I have provided is accurate.

I understand this is a private medical service, not a substitute for NHS care.

I am over 18 years of age.

I give permission to access my Summary Care Record for the purpose of carrying out a safe and effective clinical check as part of my consultation

⚠️ If you answered YES to any of the following:

• Breathing difficulties

• Inability to swallow fluids

• Stiff neck or light sensitivity

You may require urgent assessment. Please contact NHS 111 or visit A&E immediately.

We will review your form and advise you if in-person treatment is needed.