Chlamydia Consultation

You must fill in the following form before you can purchase your Chlamydia treatment

Chlamydia Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Have you or your sexual partner had a positive chlamydia diagnosis?

Are you experiencing any of the following symptoms

- Blood in the urine
- Severe pain in the lower abdomen or pelvis
- Pain, bleeding or discharge from the back passage (anus)
- Vaginal bleeding not due to period (women)
- Blisters, sores, ulcers or lumps on or close to the genitals or anus
- Brown or bloody discharge from the penis (men)
- Swollen testicles (men)
- Pain in the testicles (men)

Have you taken medication to treat chlamydia before?

If so, please provide more information

Please provide more details

Have you been diagnosed with any other medical conditions?

If so, please provide more information

Please provide more details

Have you ever been diagnosed with a mental health condition?

If so, please provide more information

Please provide more details

Are you currently taking any medications? This includes prescription only medication, over the counter medication and herbal medication

If so, please provide more information

Please provide more details

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Do you suffer with any allergies or allergies to any medications?

If so, please provide more information

Please provide more details

Is there any other information regarding your condition or medical history you would like to share with our clinical team?

If so, please provide more information

Please provide more details

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

It is strongly recommended that any individuals whom you have had unprotected sexual intercourse with since possible chlamydia diagnosis are also treated for chlamydia, would you like WePrescribe to contact these individuals on your behalf anonymously?

- If you answer yes to this question a member of the WePrescribe team will contact you to discuss this further and take details from you.
- If you answer no then we strongly recommend you contact any individuals yourself to inform them to access treatment or screening.

I have read and understood the Terms and Conditions.