Name *

First Name

Last Name

Did your GP or 111 refer you to us?

Yes

No

Not sure

I understand that the pharmacist may need to access my summary care record and I consent to this *

Yes

No

I understand that my GP will receive a summary of my consultation if appropriate *

Yes

No

Please tick if the child being treated:

is under the age of 1 or over 17

has had 3 or more episodes of an ear infection in the last 6 months

has had 4 or more episodes of ear infection in the last 12 months

is under 16 and is pregnant or there is a chance they may be pregnant

has pain, soreness, swelling, tenderness behind affected ear

has a severe headache

has a headache behind or around the eyes

is confused or irritable

has developed any muscle weaknesses

Please tick if the child being treated has any of the following symptoms:

(in older children) ear ache

(in younger children) holding, tugging or rubbing of the ear

(in younger children) generally unwell eg. fever, crying, restlessness, runny nose, cough etc