Myonlinedoctor Erectile dysfunction treatment Registration Page

In order to prescribe treatments for Herpes our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

Please select your reason for seeking treatment?

When were you first diagnosed?

Do you have another reason for seeking treatment?

Yes No

Have you suffered from Herpes before (is this a recurring episode)?

Yes No

Are you currently breast feeding or pregnant?

Yes No

Are you allergic to Doxycycline, Cefixime (Suprax), Zithromax (Azithromycin) or any antibiotics?

Yes No

I agree to contact all previous sexual partners who have a risk of infection.

I agree to follow the instructions that accompany any medicine that is prescribed. I understand that to take antimicrobial medicine without having a specific clinical indication for doing so could be harmful to my health and might lead to antibiotic resistance in the future.

I understand that there is never an absolute guarantee of effectiveness with any treatment and and this service does not include any follow-up medicine should the initial course of medicine prove unsuccessful.

I give my informed consent to be prescribed medicine according to the terms and conditions of this service.

The answers I have given in this questionnaire are true and I understand that any medicine that is prescribed is intended for use by the person whose details are given above.

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