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.

0%

Born male
Born female





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

0%


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


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


Yes
No
Not Applicable

  • G6PD deficiency
  • Porphyria (blood disorder)
  • Anaemia
  • Diabetes mellitus
  • Electrolyte imbalance
  • Debilitating conditions
  • Peripheral neuropathy (including those susceptible to peripheral neuropathy)
  • Pulmonary disease
  • Vitamin B deficiency (particularly folate deficiency).
  • Neurological disorders
  • Allergic diathesis

  • Liver problems
  • Kidney problems 
  • Bladder problems 
  • Intolerance to any sugars (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)
  • Immunosuppressed through disease, treatment or medication


If yes, what medication did you have an allergy to and what was the allergy?


  • Flank pain
  • Loin pain
  • Fever
  • Kidney pain/tenderness in back under ribs
  • Agitation or restlessness
  • Flu like illness
  • Shaking chills (rigors)
  • Nausea/vomiting








0%

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