Proctosedyl Ointment Consultation

This assessment WILL TAKE approximately 3 minutes

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Your Health Consultation

To ensure your medication is safe and suitable for you, we need to collect some essential health information. Please complete the consultation form as truthfully and accurately as possible to allow our prescribers to safely dispense your treatment.

Please provide your full name*

First Last

Gender*

Male

Female

Other

Address*

Street Address Address Line 2 City Postcode

Email*

Phone*

Date of Birth*

Day

Month

Year

Are you breastfeeding or currently pregnant?*

Yes

Medical Questions

Please ensure all information is accurate and complete to help us personalise your weight loss plan.

Are you aged over 18?*

Yes

Have you been diagnosed with any medical conditions?*

Yes

Please provide details*

Are you currently taking any medication?*

Yes

Please provide details*

Do you have any allergies or sensitivities to any medication, ingredients, or to any other substances?*

Yes

Please provide details*

Are you currently suffering with haemorrhoids/piles?*

Yes

Have you previously been diagnosed with haemorrhoids/piles by a doctor?*

Yes

Which of the following symptoms are you currently suffering from?*

Itchy bottom

A lump hanging down outside of the anus (which may need to be pushed back in after passing a stool)

A mucus discharge after passing a stool

Small amounts of bright red blood present when wiping the bottom

Soreness

Redness and swelling around your anus.

Are your symptoms the same as when you were initially diagnosed by a doctor?*

Yes

Do you suffer from any of the following symptoms:*

First time symptoms over 40 years of age

Unexpected weight loss

Unexplained rectal bleeding (especially if the blood is darker in colour)

Blood in the stools or vomit (may appear dark or sticky)

Iron deficiency (anaemia)

Difficulty swallowing

None of the above

Have you used Uniroid-HC or Proctosedyl Ointment to treat haemorrhoids/piles before?*

Yes

Please provide any additional information that you think we need to know about to safely prescribe your medication (optional)

Declaration and Consent

Please read the declaration below carefully. By submitting this consultation, you confirm that you understand and agree to the following statements.

I should not use Uniroid-HC or Proctosedyl Ointment for more than 7 days. Long-term continuous use of Uniroid-HC or Proctosedyl Ointment can cause increased side effects and thinning of the skin. I should not cover the area of application with a dressing.*

I confirm the above

Yes

I agree to see my GP if: My symptoms get worse. There is no improvement in symptoms after seven days of treatment. I experience continuous rectal bleeding, dark or sticky stools, stomach pain or unexpected weight loss.*

I confirm the above

Yes

By submitting this consultation, I confirm that I am aged between 18 and 80 years old and that I am completing this form for myself.

I confirm that the medication requested is for my own personal use only and will not be shared with any other person.

I confirm that all the information I have provided is true, complete, and accurate to the best of my knowledge, and that I have not deliberately withheld any relevant medical information.

I confirm that I have the capacity to make decisions about my own health and treatment.

I will read the patient information leaflet supplied with any medication issued and follow the instructions provided.

I confirm that I am not aware of any allergies, contraindications, or medical conditions that would make this medication unsafe for me, unless I have declared them in this consultation.

I understand that the decision to issue medication lies solely with the prescriber and that submission of this form does not guarantee that a prescription will be issued.

I agree to inform my regular GP of this consultation, any medication issued, and any relevant changes in my symptoms or medical condition.

I agree to seek medical advice from my GP or appropriate healthcare provider if my symptoms do not improve within 14 days, if they worsen at any time, or if I experience any unexpected side effects.

I understand that this service is not suitable for medical emergencies and that I should contact emergency services if I require urgent medical attention.

I confirm that I have read and agree to the i-Prescribe Terms and Conditions and Privacy Policy.

Confirmation*

I confirm the above

Consent*

I confirm the details are true and I consent to processing my health data.

Do you have an account?*

Yes

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Username*

Password*

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Benefit From Online Assessments

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Do it from the comfort of your home.

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No awkward face to face appointments

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You no longer have to wait for appointments

Need Support?

We want to make sure you get the treatment you need. If you need help completing this assessment, or prefer to complete an assessment over the phone, click below to call us.

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This assessment WILL TAKE approximately 3 minutes

Your Health Consultation

Medical Questions

Declaration and Consent

Create Account

Benefit From Online Assessments

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