Altitude Sickness - Medcare-healthclinic & Pharmacy

Are you intending to travel to a high altitude, above 3000m or suffered from altitude sickness previously?*

Yes

No

Are you over 65 years old?*

Yes

No

Do you suffer from any of the following Conditions?*

● Allergy to sulphonamides, sulphonamide derivatives including acetazolamide or to any of the ingredients in the medicine ● Severe liver or kidney problems now or previously chronic non congestive angle closure glaucoma ● Addison’s disease -adrenal insufficiency ● Low blood levels of sodium and/or potassium or high blood levels of chlorine ● Lung problems such as chronic bronchitis or emphysema

Yes

No

Are you taking any of the following medications?*

●Glycosides (e.g. digoxin) medicines to reduce blood pressure ●Anti-coagulants eg. Warfarin medicines to lower the sugar in your blood (e.g. metformin, gliclazide) ●Anti-epileptic medication (eg phenytoin, primidone or carbamazepine or topiramate) methotrexate, pyrimethamine, or trimethoprim ●Steroids such as prednisolone aspirin and related medicines, ●Other Carbonic anhydrase inhibitors (e.g. dorzolamide or brinzolamide) ●Amphetamines, quinidine, methenamine or lithium. ●Sodium bicarbonate therapy ●Ciclosporin

Yes

No

Will you be pregnant or breast feeding at any point whilst taking this medication?*

Yes

No

Do you have any known allergies to anything?*

Yes

No

If yes, please state all known allergies*

Would you like us to tell your GP about any care we provide?*

Ideally your GP should know about any medicines you’re taking.

Yes

No

Please provide your GP details*

Full name, address and post code of your GP surgery

Do you agree to:*

●1) Read the patient information leaflet included with your medication or accessed via the provided link. ●2) Use the treatment exclusively for yourself. ●3) Confirm the accuracy of all information you've provided, understanding that our prescribers rely on this information to make decisions, and incorrect information could harm your health. ●4) Understand that we may need to contact you by phone or video call to ensure the medicine is suitable. Your order may be delayed if we can't reach you when necessary. ●5) Consent to treatment from MedCare Health Clinic, affirming your mental capacity to make this decision. ●6) The treatment decision is a joint consideration between you and the prescriber, but the final decision and approval rest with the prescriber. ●7) If treatment is deemed unsuitable, you will be directed to alternative care. ●8) Seek medical advice if you experience side effects, start new medications, or if your medical conditions change during treatment. ●9) Inform your GP about this prescription, as it is best practice to notify them of any private treatment. ●10) All treatment remains confidential. ● I confirm that I am over 18 and I agree to the Terms and Conditions

Yes I agree

Name*

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Email*

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Date of Birth*