Select 'Yes' if you give permission to share this information with or seek more information from your GP, we will hold your order until GP approval has been given. Not providing consent may limit the services provided by the prescriber.

Have you seen your GP about your condition?

Are you pregnant, breast feeding or intending to become pregnant?

Are you female? (Male sufferers should source this medication from their GP as they may require further tests)

Have you been diagnosed with a Urinary Tract Infection (UTI)?

Have you taken this medication before and tolerated it well?

Typical signs and symptoms of this condition include painful urination, needing to pass urine more frequently, smelly urine. Are you experiencing any of the following? Abdominal Pain Confusion Blood in your urine Nausea or Vomiting Uncontrolled Fever

Do you have a deficiency in folic acid or Vitamin B12?

Have you been diagnosed with any of the following? • Heart, liver and kidney problems • Anaemia or other blood disorders such as Acute Porphyria • Peripheral Neuropathy (reduced sensation in hands or feet) • Diabetes • Electrolyte imbalance

Do you suffer from porphyria (a disorder that causes skin sensitivity to light, pain attacks and muscle weakness)?

Are you taking any of the following medications? • Amiodarone • Chemotherapy or related cancer drugs • Dapsone • Disulfiram • Fosphenytoin or Phenytoin • HIV medications • Isoniazid • Metronidazole

Standard T&C I will read the patient information leaflet supplied with my medication • I will contact my GP or MyMedsUK if I experience any side effects • The treatment is for my use only • I have answered the assessment questions truthfully and accurately • I agree to the Terms and Conditions and I confirm that I am over 18 years old • I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription.