Oral thrush (1 month & older)

Name

Address

Eircode

Contact Number

Scheme Number

GMSGP VisitDPSPrivate

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

Date of Birth

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

*corrected age for infants who are pre-term

Note: If your child was born prematurely this must be discussed with the pharmacist and a corrected birth age identified (>2months)

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, dentist or relevant medical practitioner.

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, dentist or relevant medical practitioner.

Has the patient been experiencing symptoms or have oral lesions for more 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, dentist or relevant medical practitioner.

Recent trauma/injury to the mouth, like a burn or open wound?
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, dentist or relevant medical practitioner.

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.