Medical Assessment for Antiviral

Patient Information  

Are you (or is your child) older than 14 years old?

Patient Symptoms  

Have you been experiencing fever/chill, cough, sore throat, runny/stuffy nose, or body aches for the past 2-5 days

OR

have you been in close contact with an individual with flu in the past 2-5 days?

Are you currently positive for COVID-19 infection?

Medical History  

Do you have allergies to oseltamivir?

Do you have a severe liver or kidney disease?

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor 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
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber