Vulvovaginal Thrush (16-60 years)

Name

Address

Eircode

Contact Number

Scheme Number

GMSGP VisitDPSPrivate

Date of Birth

Is this appointment for a person under 16 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, dentist or relevant medical practitioner.

Is this appointment for a person aged 61 years or over?
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.

Sex
MaleFemale

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.

Are you diagnosed with Diabetes mellitus (type 1 or type 2)?
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.

Have you already been prescribed a treatment for this episode of thrush and have ongoing symptoms still present?
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.

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.