Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Tell us about your current symptoms so we can check if treatment is appropriate. *

What symptoms are you experiencing?

Itching

Soreness

Thick white discharge

Discomfort during sex

Burning when passing urine

None

Consent & Declaration *

I confirm the information provided is accurate to the best of my knowledge.

I understand this consultation is for simple, uncomplicated vaginal thrush.

I will seek medical advice if symptoms persist, worsen, or recur frequently.

I consent to this information being used to assess my suitability for treatment.