Assessment for Cystitis (UTI)

(tick all that apply)

(tick any that apply)

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for this assessment. 

I agree to consult with my healthcare provider before starting any new medication. 

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed. 

I have been informed about the potential side effects and interactions of the prescribed medication for cystitis. Specifically, I confirm that I have been informed of the following:

• Purpose of treatment and expected benefits
• Possible side effects (e.g., nausea, diarrhoea, rash, changes in urine colour)
• Potential risks (e.g., antibiotic resistance, allergic reactions, liver effects)
• Need to complete the full course even if symptoms improve
• Need to report any side effects or if symptoms worsen

I consent to receive treatment for Cystitis (UTI) through this online service and understand that my information will be used in accordance with clinical and data protection regulations.