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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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

  • Slight rectal bleeding (spotting when wiping)
  • Dull pain on defecation 
  • Prolapsing outside of anus
  • Swelling inside the anal canal
  • Itching & burning in anal area
  • Swelling & soreness

Please provide more information and any other symptoms you may have .


  • Blood in stool: This differs from spotting. Blood in the stool usually appears dark red and is mixed in with the stool.
  • Abdominal pain, fever, nausea, and vomiting.
  • Loss of appetite.
  • Altered bowel habits.
  • Severe, sharp pain during defecation.
  • Symptoms lasting longer than 3 weeks.
  • No improvement after using over-the-counter medication for 1 week.



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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
  • 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.