To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Born male
Born female




Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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This may be to any medicines or other substances e.g. peanuts/soya)


Either prescribed or over the counter, including herbal remedies, supplements, or recreational drugs.


Yes
No
Not applicable

  • Osteoporosis
  • Kidney problems 
  • Liver disease
  • Jaundice
  • Heart problems


  • Heartburn (burning sensation in the middle of your chest)
  • Acid regurgitation (a sour taste in your mouth)
     


  • Significant unintentional weight loss
  • Recurrent vomiting
  • Dysphagia (swallowing problems)
  • Haematemesis (vomiting food or blood, which may appear as dark coffee grounds in your vomit)
  • Melaena (blood stained faeces)

  • Cough or hiccups that keep coming back
  • A hoarse voice
  • Bad breath
  • Bloating and feeling sick




Such as Gaviscon or Rennie tablets



E.g. fructose intolerance, glucose-galactose
malabsorption or sucrase-isomaltase insufficiency




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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • You understand that this treatment is for short term use only
  • Y0u confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.

Please ensure the medication is stored safely out of reach of young children or pets to prevent accidental ingestion.


Please state your registered GP if you haven't done so already when signing up