Patient Information

Are you (or is your child) 12 years old or older?

For females, are you pregnant or breastfeeding?

Patient Symptoms
Have you been told by your doctor that you have genital herpes?

OR

Do you have any of the following symptoms?

• Shingles (painful rash that turns into fluid-filled blisters on one side of the body/
  face)?
• Cold sores or painful blisters around the lips or under the nose

OR

Have you been tested positive for herpes after a blood, swab,
or urine test?

Medical History
Do you have an allergy to valacyclovir or similar drug?

Do you have any of the following?

• Kidney disease
• Liver disease
• Bladder disease
• HIV/AIDS
• Other sexually transmitted infections (STI’s)

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber