Are you suffering from symptoms of acid reflux? examples include:

• Heartburn - Discomfort, pain, acidic sensation, or burning pain in the chest area
• A sharp or gripping pain that may radiate to the throat and back and can be associated with acid regurgitation, exacerbated by eating large meals, bending over, or lying flat, especially in bed at night. 

Are you over the age of 55 years AND either:

• Experiencing these symptoms for the FIRST time OR your symptoms have recently changed?
• OR have unexplained indigestion that HAS NOT responded to treatment?

Are you breastfeeding, pregnant, or possibly pregnant?

• Currently suffering from or have had a Gastric Ulcer or have Gastric Cancer
• Due to have surgery, an endoscopy, or a C-urea test
• Have symptoms of jaundice (Skin, whites of the eyes and mucous membranes turn yellow) or any other liver condition or liver impairment
• Have a history of gastrointestinal disorders (e.g. ulcerative colitis, Crohn’s disease)
• Have gastrointestinal bleeding, a history of gastrointestinal bleeding and/or are anaemic
• Have an active gastrointestinal ulceration or a history of gastrointestinal ulceration
• Have a history of intestinal haemorrhage
• Have severe heart failure, ischaemic heart disease, peripheral arterial disease or uncontrolled high blood pressure?
• Have an epigastric mass, recurrent vomiting or unexplained weight loss
• Experience stomach pain, pain when swallowing or difficulty swallowing
• Suffer from Hypomagnesaemia (low magnesium in the blood)
• Have Osteoporosis

Are you currently taking any medication, whether prescribed or not by your doctor, including over-the-counter medication, remedies, or recreational drugs?

Does any of the following apply to you?

• Are you Asthmatic or have ever been Asthmatic?
• Are you taking Asprin or any medication that thins the blood (e.g Warfarin, Apixaban) or have any coagulation defects?
• Are currently taking any other anti-inflammatory medication?
• Are currently taking any steroid medication (e.g Prednisolone)?

DISCLAIMER Please consent to the following:

• I confirm the above questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
• I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from e Shop Pharmacy
• I confirm I will take the medication as prescribed or directed for its intended use and if I am not requesting the starting dose for that medication, I have taken the medication previously on that dose and without any side effects
• I have read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
• All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for e Shop Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
• I am happy to be treated by the prescribers and health care professionals at e Shop Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
• I understand long-term use of some NSAIDs is associated with reduced female fertility, which is reversible upon stopping treatment
• I understand lifestyle factors such as weight, smoking, eating heavy meals, fatty foods, spicy foods, and drinking alcohol may contribute to acid-reflux symptoms
• I understand taking proton pump inhibitors may increase the risk of gastrointestinal infections such as salmonella or campylobacter.
• I have read and accept the terms & conditions and privacy policy