Shingles (18 years & over)

Name

Address

Eircode

Contact Number

Scheme Number

GMSGP VisitDPSPrivate

Date of Birth

Is this appointment for a person under 18 years of age?
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 you pregnant, suspected pregnant or breastfeeding?
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.

Does your suspected case of shingles include the eye/ocular area?
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.
Assessment by an eye specialist is advisable within 24-48 hours.

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.