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 you or the child being treated:

are aged 17 years or under

are pregnant or there is a chance you may be

are immunosuppressed

are experiencing redness of the eyes or vision problems

have a rash on your nose

have a fever

have a headache

Have a rash which:

began as a burning, stabbing, throbbing, itching or tingling sensation

appeared initially as red spots on a pink/red background

some blisters have now burst, others filled with pus or blood.

the area surrounding rash is dry, with crusts and scabs forming

is only on one side of your body

Have a rash which appeared between 3-7 days ago:

(Tick those that apply)

appeared between 3-7 days ago

is affecting your neck, limbs, anus or genital area

is causing you moderate to severe pain

you are aged 50 or over

Have a rash which appeared over 7 days ago:

(Tick those that apply)

IS CAUSING YOU SEVERE PAIN

IS NOT HEALING

YOU HAVE SEVERE ATOPIC DERMATITIS, ECZEMA, OR OTHER SKIN CONDITION

YOU ARE AGED 70 OR OVER