Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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Your Symptoms

Are you aged over 50 with new or recently changed symptoms?

Yes

Unable to proceed, please consult your GP.

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Are you experiencing acid reflux at least twice a week? Symptoms include:

Heartburn - a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours
Chest pain, especially after bending over, lying down or eating
Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat
Feeling of food "sticking" in the middle of the chest or throat

Yes

We are unable to supply you with acid reflux medication for treating other conditions. Please consult your GP for the treatment of any other condition.

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Are you experiencing any of the following?

difficulty swallowing
unintentional weight loss
abdominal swelling
persistent vomiting
severe/persistent diarrhoea
vomiting blood
blood in your stools or black, tarry stools
have iron deficiency anaemia
severe liver problems

Yes

Consult your GP urgently. These symptoms indicate the possibility of a more serious illness.

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Your Health

Are you breast feeding or pregnant or possibly pregnant?

Yes

We are unable to supply you with acid reflux medication. Please consult your GP.

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Do you have an allergy (hypersensitivity) to medicines containing proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?

Yes

We are unable to supply you with acid reflux medication. Please consult your GP.

Please complete this question.

Do you have any of the following conditions:

Osteoporosis
Liver problems
Gastric cancer
Hypomagnesaemia (low magnesium in the blood)

Yes

We are unable to supply you with acid reflux medication. Please consult your GP.

Please complete this question.

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?

Yes

Proton Pump Inhibitors have very occasionally been found to be associated with a condition called “Subacute Cutaneous Lupus Erythematosus (SCLE). Please discuss your rash with your doctor. If you have already discussed your rash with a doctor and have a clear diagnosis confirming your rash is not SCLE, please change your answer to NO and continue.

Please complete this question.

Your Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes

Are you taking any of the following medications?

NSAID anti-inflammatory painkillers (e.g. ibuprofen)
Ketoconazole, itraconazole, posaconazole or voriconazole (used to treat infections caused by a fungus)
Digoxin (used to treat heart problems)
Diazepam (used to treat anxiety, relax muscles or in epilepsy)
Ulipristal (used as emergency contraception or treatment for fibroids)
Phenytoin or Fosphenytoin (used in epilepsy)
Medicines that are used to thin your blood, such as warfarin or other vitamin K blockers.
Rifampicin (used to treat tuberculosis)
Atazanavir, Rilpivirine, Tripranavir, Saquinavir, Nelfinavir, Raltegravir (used to treat HIV infection)
Ledipasvir (used for Hepatitis C treatment)
Ciclosporin or Tacrolimus (in cases of organ transplantation)
St John's wort (Hypericum perforatum) (used to treat mild depression)
Cilostazol (used to treat intermittent claudication)
Clopidogrel (used to prevent blood clots (thrombi))
Vitamin B12, Cyanocobalamin, Hydroxocobalamin
Erlotinib, Dabrafenib, Lapatinib or Pazopanib (for cancer treatment)
Clarithromycin (an antibiotic)
Methotrexate (for cancer or rheumatoid arthritis treatment)
Escitalopram (an antidepressant)
Clozapine (for schizophrenia)

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

Please complete this question.

Agreement

Do you understand that acid reflux treatment supplied through this service can only be used for the short-treatment of gastroesophageal reflux disease (GORD) also known as heartburn/acid indigestion for a maximum of 28 days?

Yes

We are unable to supply you with acid reflux medication for treating other conditions. Please consult your GP for the treatment of any other condition.

Please complete this question.

Do you understand that healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable?

Yes

If you need more information on lifestyle advice contact our helpline.

Please complete this question.

Do you understand that if you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment?

Yes

We are unable to supply you with acid reflux medication for treating other conditions. Please consult your GP for the treatment of any other condition.

Please complete this question.

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

Please complete this question.

Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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