Bacterial Vaginosis Treatment Consultation

Personal Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

MM

DD

YYYY

Phone number? *

Address? *

Email? *

Have you ever been diagnosed with Bacterial Vaginosis before? *

YES NO

What type of medication was prescribed to you last time? *

ORAL

Oral treatment is in the form of tablet

TOPICAL/VAGINAL

Topical treatment gel/ointment

NEVER USED ANY MEDICATION

Are you looking for oral or topical/vaginal gel treatment? *

ORAL TOPICAL/VAGINAL

Are you currently pregnant? Or planning to become pregnant in next few months? *

YES NO

Current Medications

Please provide details about your current medications

Are you currently taking any prescription, non prescription or illegal drug or herbal medication? and have you recently taken any medication in the last two weeks? please specify. *

NO YES

If YES, please specify:

Do you any past medical or surgical history that you want to inform our doctor about? *

NO YES

If YES, please specify:

Allergies & Final Details

Please provide allergy information and final details

Please specify if you have allergy to any medication or any other substance? *

NO YES

If YES, please specify more information about the allergies you have to medicines or tablets:

Please specify your gender? *

FEMALE MALE

Please specify the name of preferred pharmacy where you want to collect your prescription/medications? *

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge. *

YES NO

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Review your details and complete payment

Consultation Summary

Bacterial Vaginosis Consultation Fee

GP Review + Prescription

€25.00

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Bacterial Vaginosis Treatment

Personal Information

Treatment History & Symptoms

Medical History

Current Medications

Allergies & Final Details

Checkout

Consultation Summary

Bacterial Vaginosis Consultation Fee