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 the age of 5

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

has had a change in their voice (hoarse, raspy or strained)

is having difficulty swallowing

is drooling

is immunosuppressed

has visible swelling of the neck

is experiencing pain in their neck

has recently developed a rash

has a white coating on tongue or tongue has red appearance

has a flushed face

is feeling generally unwell

has symptoms that appeared less than 3 days ago

does not have cough/cold symptoms

has a fever

has severely inflammed tonsils

has visible pus on tonsils