Infective Conjunctivitis (6 months & 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 2 months* of age?
YesNo

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

Are you wearing contact lenses?
YesNo

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please contact an emergency eye service or attend your local hospital.
Please remove contact lenses while awaiting referral.

Are you suffering from any of the below symptoms?

Changes and/or loss of vision including blurred vision

Moderate to severe eye pain

History of recent eye trauma including recent eye surgery

None of the above

Unfortunately your response indicates that you are not suitable for treatment in the Pharmacy at this time. Please contact an emergency eye service or attend your local hospital.

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.

Infective Conjunctivitis (6 months & over)