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Please answer the following questions for our prescribers to review
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Acid Reflux >> Omeprazole 20mg Capsules

Are you experiencing any heartburn/acid reflux at least twice a week?

    Symptoms include
  • A burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours
  • Chest pain, especially after bending over, lying down or eating
  • Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat
  • Feeling of food "sticking" in the middle of the chest or throat

Do you suffer from any of the following?

  • difficulty swallowing
  • unintentional weight loss
  • abdominal swelling
  • persistent vomiting
  • severe/persistent diarrhoea
  • vomiting blood
  • blood in your stools or black, tarry stools
  • have iron deficiency anaemia
  • severe liver problems
Do you have an allergy (hypersensitivity) to medicines containing proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?
Will you be pregnant or breastfeeding at any point during this treatment or whilst taking this medication. ?
Do you have any of the following conditions:
  • Osteoporosis
  • Liver problems
  • Gastric cancer
  • Hypomagnesaemia (low magnesium in the blood)
Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?
Are you currently taking any other medication such as over the counter, prescription or recreational drugs?
Do you understand that healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable?
Do you understand that acid reflux treatment supplied through this service can only be used for the short-treatment of gastroesophageal reflux disease (GORD) also known as heartburn/acid indigestion for a maximum of 28 days?
Do you understand that if you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment?
  • 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