Select 'Yes' if you give permission to share this information with or seek more information from your GP, we will hold your order until GP approval has been given. Not providing consent may limit the services provided by the prescriber.

1. Have you seen your GP about your condition?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

2. Are you pregnant, breast feeding or intending to become pregnant?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

3. Have you taken this medication before and tolerated it well?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

4. Have you been diagnosed with Dyspepsia (indigestion)?

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

5. The following symptoms may indicate that you require further investigations to look into the cause of your symptoms and we therefore recommend that you discuss the matter with your GP. Do you suffer with any of the following? • Persistently worsening indigestion • Associated vomiting or ever vomited blood • Unexplained weight loss • Difficulty swallowing • Black stools • Persistent diarrhoea • Low sodium or Magnesium in your blood.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

9. Have you been diagnosed with any of the following? • Kidney or Liver problems • Gastric Ulcers • Cutaneous Lupus • Osteoporosis

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Are you taking any of the following medications? • Antifungals e.g. Ketoconazole • HIV medication • Chemotherapy or related cancer drugs • Cilostazol • Citalopram • Chemotherapy or related cancer drugs • Clopidogrel • Dipyridamole • Escitalopram • HIV medication • Methotrexate

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

Standard T&C • I will read the patient information leaflet supplied with my medication • I will contact my GP or MyMedsUK if I experience any side effects • The treatment is for my use only • I have answered the assessment questions truthfully and accurately • I agree to the Terms and Conditions and I confirm that I am over 18 years old • I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription.

Sorry we cannot supply you with this treatment on this occasion. Please see your GP for further advice.

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