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:

is under 12 years old

is immunosuppressed

has chronic sinusitis (symptoms lasting for longer than 12 weeks)

is under 16 years and may be pregnant

has new reduced vision

has other conditions around eyes

has swelling of the forehead

has a severe headache

Please tick if you or the child has any of the following symptoms:

Nasal blockage or runny nose

pain or pressure in the face or head

reduction or loss of smell (adults only)

cough during the day or at night (children only)

symptoms for more than ten days