QuickScript Online Consultation Form

Welcome to QuickScript! Please complete this secure form to start your online consultation with an independent prescribing pharmacist.

Important Eligibility Criteria - Please Read Carefully

This service is suitable ONLY for experiencing typical UTI symptoms without red flag signs. If you fall outside this criteria or have 'red flag' symptoms (e.g., fever, back pain, nausea), please seek in-person medical attention from your GP or A&E as this service may not be suitable.

This service is for minor conditions. If you are experiencing a medical emergency, please call 999 or go to your nearest A&E.

The consultation fee is non-refundable if the pharmacist determines your condition is not suitable for online treatment and refers you to a GP or emergency services.

2. Medical History & Allergies:

Current Medications:

Relevant Medical Conditions:

Are you Pregnant/Breastfeeding?

Yes - Pregnant

3. UTI-Specific Symptoms & History

What is your gender assigned at birth?

Male

Which of the following symptoms are you experiencing? (Select all that apply)

Pain or burning sensation when urinating (dysuria)

Needing to urinate more often than usual (frequency)

Cloudy or strong-smelling urine

Lower abdominal pain/discomfort

Pain above the pubic bone

Are you experiencing any of the following (select all that apply)?

Fever (temperature above 38°C / 100.4°F)

Pain in your back or side (kidney area)

Blood in your urine (visible)

Have you had a UTI in the last 3 months? If so, how many?

Terms & Privacy Consent:

I confirm that I have read, understood, and agree to QuickScript's [Privacy Policy] and [Terms of Service].

I agree

I understand that the consultation fee covers the assessment and potential prescription, but , which I will pay separately at the pharmacy.

I agree

I understand that the QuickScript pharmacist may determine my condition is not suitable for online treatment and may refer me to a GP or emergency services for an in-person assessment.

I agree

I confirm that all information provided in this form is accurate and truthful to the best of my knowledge.

I agree

QuickScript Online Consultation Form - UTI

Important Eligibility Criteria - Please Read Carefully

1. Personal Details

Full Name:

Date of Birth:

Email Address:

Phone Number:

Current UK Address:

2. Medical History & Allergies:

Known Allergies:

Current Medications:

Relevant Medical Conditions:

Are you Pregnant/Breastfeeding?

3. UTI-Specific Symptoms & History

What is your gender assigned at birth?

Detailed Symptoms

Which of the following symptoms are you experiencing? (Select all that apply)

Are you experiencing any of the following (select all that apply)?

Have you had a UTI in the last 3 months? If so, how many?

Payment

I confirm that I have read, understood, and agree to QuickScript's [Privacy Policy] and [Terms of Service].

I understand that the consultation fee covers the assessment and potential prescription, but , which I will pay separately at the pharmacy.

I understand that the QuickScript pharmacist may determine my condition is not suitable for online treatment and may refer me to a GP or emergency services for an in-person assessment.

I confirm that all information provided in this form is accurate and truthful to the best of my knowledge.