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Please answer the following questions for our prescribers to review
and issue FREE online prescription.
Asthma >> Ventolin Evohaler 100 micrograms

Are you aged between 18-75?

Do you smoke?

In the last year have you ever been hospitalised or had to visit A+E due to your asthma?

Have you previously been prescribed a salbutamol inhaler by a doctor or nurse?

Are you taking any other medication including other asthma medication?
Are you confident that you know how to use your inhaler correctly?
Have you had an asthma review by your doctor or nurse in the last 12 months
Have you been prescribed Ventolin in the last 12 months?
Do you have an allergies to this medication ?
Are you breast feeding or pregnant, think you may be pregnant or planning to have a baby
Do you suffer from any of the following
  • High blood pressure
  • An overactive thyroid gland
  • a History of heart problems such as an irregular or fast heartbeat or angina
Are you currently taking any prescription only medication, over the counter medication or recreational drugs
I am aware that I should seek urgent medical help if I experience the following
  • I use my salbutamol inhaler more than 4 times a day
  • My breathing is getting worse despite using the treatment
  • I experience chest pain or chest tightness after using my inhaler
  • Your asthma does not improve within 1 hour of using an inhaler
For the supply of this medication, we are required to inform your regular GP.



  • To read the patient information leaflet this will be given to you with your medication
  • To keep us and your GP informed when you start a new medication, if your medical condition changes during treatment or if you experience any side effects of treatment.
  • That the medication we supply you with will be only for your own personal use.
  • That you have answered the above questions truthfully and accurately. Our prescribers base their prescribing decisions on the answers you give and that any information you have provided that may be incorrect could have a detrimental effect on your health.
  • I declare that the information I have supplied is both complete and truthful and I agree to read the patient information leaflet provided before using this medication.*
  • I declare that I agree with the Customer Responsibility Statement*
  • I declare that I agree with the Informed Consent Agreement*
  • I declare that I agree with terms & Conditions and Privacy Policy