Cold sores (1 month & over)

Name

Address

Eircode

Contact Number

Scheme Number

GMSGP VisitDPSPrivate

Name of Parent/Guardian (if patient under 16 years)

Date of Birth

If your child was born prematurely please contact the pharmacist so a corrected birth age can be identified. Please contact the pharmacy before proceeding any further.

Is this appointment for a child under 1 month* of age?
YesNo

Your response indicates you require URGENT MEDICAL ASSESSMENT and are not suitable for treatment in the pharmacy. Please seek treatment from a GP/GP out of hours/ Hospital emergency department as soon as possible.

Are you pregnant, or suspected pregnant?
YesNo

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please make an appointment with your GP, treating obstetrician, or gynaecologist.

Have you had symptoms for longer than 14 days?
YesNo

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please make an appointment with your GP or relevant medical practitioner.

Are the lesions present involving the eye/opthalmic area?
YesNo

Please add any other relevant information or symptoms that you want the pharmacist to know in the box below.

GP Details*

Name

Address

Contact Number

*Not mandatory

Select store for consultation

Consent

Do you consent for the pharmacist on duty to review the information you provided above and if you are deemed a suitable candidate, for them to contact you to organise a suitable time for the consultation.