To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Tummy pain that comes on suddenly.
Chest ache that is unbearable.
Blood or what appears to be coffee granules in your vomit.
High temperature and a stiff neck.
A strong headache that is unlike any other headache you've ever had.
Do you require assistance?

Please select your option
Everyday
Once or twice a week
Once a week
At least two weeks
On a monthly basis
A few times a month

Have you been vomiting for more than two days?
Vomiting so much that you can't keep any liquids down?
Green vomit which serves as an indication of a bowel blockage?
Signs of dehydration such as feeling confused, having a quick heartbeat, sunken eyes, and passing little or no urine?
unplanned and rapid weight loss?
Suffering from a fever, chills, headache, or diarrhoea?
Do you require assistance?


You can select more than one option
Gagging
Vomiting
Dizziness
Diarrhoea

If so, please tell us what they said caused your nausea.
Do you require assistance?

Notably, if you are unsure about the reason for your nausea, we urge that you visit your doctor for a thorough examination.


If yes, how successful was it?

Epilepsy.
Glaucoma.
Parkinson's disease, a neurological disorder.
Any ailment that affects the blood.
Prostate issues.
Myasthenia gravis.

You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

If your condition does not improve after four weeks, you should consult a doctor.
You must not use Enstilar on broken skin or beneath a bandage.
You cannot use Enstilar aound the eyes or on the eyelids.

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Please provide more information of the medication being used if any.

Please select your option
Presently Pregnant
Presently Breastfeeding
Planning on getting pregnant
Neither Pregnant nor Breastfeeding

Please select your option
Male
Female
Transmale (Born a female)
Transfemale (Born a male)



Renal / kidney problems, Liver problems, Seizure disorders (e.g. epilepsy), Parkinson's disease, Adrenal gland tumour, Methaemoglobinaemia (abnormal blood pigment levels), NADH cytochrome-b5 deficiency, Porphyria, Neurological problems

If yes, please provide details







If yes, please describe the product and the reaction


If yes, please provide details

If yes, please provide details

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If yes, please provide details





Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
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