Urinary Tract Infection Consultation *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Consent & Declaration *

I confirm that I am completing this consultation for myself (not on behalf of someone else).

I am over 18 years of age and identify as female.

I have previously had a diagnosis of a urinary tract infection (UTI) and recognise the symptoms.

I am not pregnant, breastfeeding, or trying to conceive

I do not have symptoms that suggest a kidney infection (e.g. flank pain, high fever, nausea/vomiting).

I am not experiencing symptoms of a sexually transmitted infection.

I understand that this service is not a substitute for a face-to-face examination if symptoms worsen or do not improve.

I will seek urgent medical attention if my symptoms worsen, persist for more than 48 hours after starting treatment, or if I become unwell.

I understand that a private prescription will be issued if suitable and that this is not an NHS service.

☐ I understand that the prescriber may refuse to issue treatment if it is not clinically appropriate.