UTI and Cystitis Treatment Consultation

Personal Information & Medical History

Please provide your details accurately

Date of birth? *

YYYY

Duration of your symptoms? Did the symptoms start gradually or suddenly? *

Any past medical history of recurrent (UTIs) urinary tract infections? *

NO, I'VE NOT YES

If YES, please specify:

Are you having blood in the urine? *

NO, I HAVE NOT YES I HAVE

If YES I HAVE, please specify:

Do you have any urinary catheter inserted? *

NO, I'VE NOT YES I DO

If YES I DO, please specify:

Have you ever had a Urine culture by your GP? *

Do you have any renal tract abnormality? (e.g., blockage) *

NO, I'VE NOT YES I HAVE

If YES I HAVE, please specify:

Do you have any past medical or surgical history that you want to mention to our doctor? *

NO, I'VE NOT YES I HAVE

If YES I HAVE, please specify:

Are you on any regular medications? If yes please specify below. *

Have you used the course of antibiotics recently for UTI or Cystitis? *

NO, I'VE NOT YES I HAVE

If YES I HAVE, please specify:

Symptoms & Additional Details

Please select all symptoms that apply and provide additional information

Please specify the symptoms that you are experiencing? *

Select all that apply:

Pain, burning or stinging when passing urine Passing urine more than usual at night Cloudy looking urine Urgent need to urinate Lower abdominal pain or discomfort Strong smelling urine None of the above

If OTHER SYMPTOMS, please specify:

Are you suffering with abnormal vaginal discharge? *

NO, I DON'T YES I DO

If YES I DO, please specify:

Do you have uncontrollable shivering, flank pain, vomiting and fever? *

If yes, you need to be seen physically in one of our clinics.

NO, I DON'T YES, I DO

Please contact our freephone number:

(0818) 000 365

These symptoms may indicate a more serious infection that requires in-person assessment.

Are you pregnant or breastfeeding? *

NO YES, I AM

Are you allergic to any medication or any substance? *

NO YES

If YES, please specify:

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

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Review your details and complete payment

UTI & Cystitis Consultation Fee

GP Review + Prescription

UTI & Cystitis Treatment

Personal Information & Medical History

Symptoms & Additional Details

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Consultation Summary

UTI & Cystitis Consultation Fee