Cystitis Consultation – Newgen Pharmacy

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Quick login consent(Required)

I Understand(Required)

First Name(Required)

Middle Name

Last Name(Required)

Email(Required)

Telephone(Required)

Address(Required)

Street Address City ZIP / Postal Code

What was your assigned sex at birth?(Required)

This online consultation depends on knowing your assigned sex at birth, not your gender identity. We need to know this information so we can ask relevant clinical questions and recommend suitable treatments.

Male

Female

⚠️

Unable to prescribe: You can only be prescribed treatment for this condition if you are female.

What is your date of birth?(Required)

DD slash MM slash YYYY

Do you confirm that:(Required)

You understand that it is in your best interests to answer all questions in full, providing accurate and honest information.
You are using this service yourself, of your own free will and any medicine is for your personal use only.
You have capacity to understand all about the condition and medication information we have provided in advance and that you give fully informed consent to the treatment option provided in your best interests.
You have read and fully understand what this medicine is used for, as well as all the possible treatment options for your condition and are aware of all the possible benefits, risks or side effects.
You agree to read the patient information leaflet before taking any medicine and use the medication only as directed.

I understand

Do you feel confident in recognising the symptoms of cystitis?(Required)

Yes

⚠️

Unable to prescribe: This medication cannot be prescribed online. Please consult your GP for further advice.

Have you ever had cystitis that has spread to your kidneys or required you to attend hospital?(Required)

Yes

Do any of the following apply?(Required)

Was this episode in the last 12 months?
Have you needed to attend the hospital more than once for symptoms?
Have you ever been diagnosed with sepsis?
Have you ever needed intravenous treatment?

Yes

⚠️

Unable to prescribe: This medication cannot be prescribed online. Please consult your GP for further advice.

Do you have a urinary catheter (a tube that goes into your bladder to drain urine into a bag)?(Required)

Yes

⚠️

Unable to prescribe: This medication cannot be prescribed online. Please consult your GP for further advice.

Have you had recurrent UTIs (2 UTIs in the last 6 months or 3 UTIs in the last 12 months)?(Required)

Yes

⚠️ Unable to prescribe: This medication cannot be prescribed online. Please consult your GP for further advice.

Are you pregnant or is there any chance that you could be pregnant?(Required)

Yes

Possibly

⚠️ Important: You cannot be prescribed this medication online if you are pregnant or if there is any possibility you might be pregnant. If needed, take a pregnancy test to check. If the result is positive, please see your GP.

There could be an alternative cause for your symptoms. Do you have any of the following symptoms?(Required)

Abnormal vaginal discharge

Sudden pain during or after sexual intercourse

Urinary or vaginal symptoms linked to the menopause

No, none of these

⚠️ Important: Please see your GP for a diagnosis, as there is a high likelihood this may not be a urinary tract infection.

Are you experiencing any of the following symptoms?(Required)

- Burning sensation when urinating
- Sudden urge to urinate at night
- Cloudy urine

1 symptom

2 symptoms

3 symptoms

None of these symptoms

⚠️ Important: Please see your GP or call 111 as you need a urinary dip stick test especially if you have any other symptoms such as blood in the urine, increased urgency or frequency to pass urine, or it is painful over your bladder area.

Please specify which two symptoms:(Required)

Dysuria & Nocturia

Dysuria(pain during urination)

Nocturia & cloudy urine

Other

Is there a chance your symptoms could be due to the following?(Required)

A sexually transmitted infection (STI)
A recent vaginal, bladder or kidney procedure such as having a coil inserted
Termination of a pregnancy

Yes

⚠️ Important: Please call 111 or see a doctor urgently.

Is there a chance your symptoms could be due to the following?(Required)

Fever or a feeling of being hot and cold
Rigours (shaking)
Severe back pain
Visible blood in the urine
Vomiting or diarrhoea

Yes

⚠️ Important: Please call 111 or see a doctor urgently.

Do you have a condition that suppresses your immune system?(Required)

Yes

⚠️ Important: Please call 111 or see a doctor urgently.

Are you breastfeeding or planning on conceiving?(Required)

Yes

⚠️ Important: You cannot be prescribed online if you are breastfeeding or planning to conceive.

Do you have any allergies?(Required)

Yes

Please provide more information.(Required)

Have you ever had any medical conditions or surgery not previously mentioned in this form, or is there any further information you would like to provide the doctor?(Required)

Yes

Please provide more information.(Required)

Select A treatment(Required)

Prices include next-day delivery and prescription

Nitrofurantoin

Recommended Doses(Required)

Consent(Required)

Please confirm that you understand the following regarding antimicrobial prescribing:

If you experience any of the following symptoms of sepsis, seek urgent medical attention from your GP or go to A&E immediately:

- Sudden episodes of feeling very hot and cold, with body shakes (rigors)

- Confusion, slurred speech, or difficulty making sense

- Trouble breathing, breathlessness, or rapid breathing

- Blue, grey, pale, or blotchy skin, lips, or tongue (on darker skin, more visible on the palms of the hands or soles of the feet)

Taking antimicrobials can contribute to antimicrobial resistance, which may make future treatments less effective. Medication will only be prescribed when it is clinically appropriate.

I confirm

Have you ever experienced an allergic reaction or undesirable side effect when taking nitrofurantoin?(Required)

Yes

⚠️ Important: It may not be safe for you to be prescribed online if you have experienced issues with this medication.

Please confirm you understand the following regarding antimicrobial prescribing:

Please confirm you understand the following regarding antimicrobial prescribing:

Seek urgent medical care from your GP or A&E if you experience any of the following signs of sepsis:

Feeling hot and cold with body shakes (rigours)

Confusion, slurred speech, or not making sense

Difficulty breathing, shortness of breath, or rapid breathing

Blue, grey, pale, or blotchy skin, lips, or tongue (on darker skin, check palms or soles)

Antimicrobial use may increase resistance, making future treatments less effective. Treatment will only be issued when clinically appropriate.

I confirm.

Have you ever been diagnosed with any of the following?(Required)

Abnormal material in the blood (blood dyscrasias)
Acute porphyrias
Cardiovascular (heart) problems
Kidney or liver problems
Blood disorders e.g. anaemia or folic acid deficiency
Abnormalities of the bladder
G6PD deficiency
Diabetes
Electrolyte imbalances
B9 or B12 deficiency (folate deficiency)
Pulmonary disease
Susceptibility to peripheral neuropathy

Yes

⚠️ Unable to prescribe: You cannot be prescribed this medication online, please see your GP.

Do you take any other medicines including prescription, over-the-counter or recreational drugs?(Required)

Yes

Please provide the name and dose of all medicines you are currently taking.(Required)

Please tell us which medical conditions you are taking these medications for.(Required)

Do you consent for us to inform your GP, and if necessary, have a dialogue so that we can provide effective ongoing continuity of care?(Required)

Yes - Please inform my GP

No - I will inform my GP myself

GP Full Name(Required)

GP Email(Required)

GP Postcode or city(Required)

⚠️ Important: Please note that it is in your best interest for your GP to be informed about the details of this consultation. This ensures your medical records remain accurate and up to date with:

Any changes to your regular medications
The addition of new medications
Monitoring needs such as blood tests
Any newly identified allergies or adverse reactions

As NewGen Pharmacy is not your regular healthcare provider, any treatment provided is given on the understanding that you will share this information with your GP for your own safety.

Consent(Required)

I have read and accept the Terms & Conditions, Patient Responsibility, Privacy Policy and Cookies Policy

I agree to the privacy policy.

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