PGD Test - Holborn Pharmacy

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TEST PGD

This is just a test, select which one you want, and it will ask you questions according to the PGD
Give it a try

"*" indicates required fields

Step 1 of 5

20%

Name

First Last

Choose the private prescription you require*

Address

Street Address City / Town State / Province / Region Postcode Country

Date of birth*

DD slash MM slash YYYY

Gender*

NHS Number

Ethnicity (print separately):*

Your email*

Telephone number*

GP Name

Otomize Ear Spray

Patient over 2 years of age presenting with symptoms of acute, localised otitis externa*

YES

NO

Patient medication and comment*

Patient under 2 years of age, i.e. up to the 2nd birthday*

YES

NO

Hypersensitivity to neomycin, dexamethasone, glacial acetic acid or to any of the excipients*

YES

NO

Patient with a diagnosed, or suspected perforated tympanic membrane, or where a tympanostomy tube (grommet) is in situ*

YES

NO

Our you a Breastfeeding women?*

YES

NO

Our you a Pregnant women?*

YES

NO

Do you have kidney disease?*

YES

NO

Do you have liver disease*

YES

NO

Phenoxymethylpenicilli

Reason for incluion*

YES

NO

Patients over the age of 12 years with a Centor score of 3 to 4, and a positive test using OSOM Strep A test (Centor criteria:Tonsillar exudates, Tender anterior cervical adenopathy, Absence of cough, History of feve

Do you have renal failure?*

YES

NO

Do you use the following drugs*

Bacteriostatic antibiotics such as tetracycline, erythromycin, chloramphenicol and sulphonamides

Methotrexate

Neomycin

Potassium containing drugs

Potassium sparing diuretics

Our you on a low potassium diet?*

YES

NO

Email

This field is for validation purposes and should be left unchanged.

Opening hours

Monday – Friday 9am – 6 pm
Saturday 9am – 5pm
Sunday Closed

Contact us

0207 405 28 25

Address
88 Southampton Row, Holborn, London WC1 B4BB

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