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 you or child being treated:

is under the age of 1

is under the age of 16 and is pregnant or they may be pregnant

Has previously had impetigo less than a year ago

has fluid filled blisters approx 1-2cm across in the affected area (bullous impetigo)

is immunosuppressed

is otherwise unwell eg has a fever

has red patches of skin and lesions which rupture easily and dry to form yellow/brown crusts