About your condition and treatment
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.
What age are you (or the person who will use this medication)?
Do you have any cardiovascular conditions or have you suffered a stroke
Are you female?
Please select any conditions that apply
What is your biological gender?
Please select your option
Have you (or the person who will use this medication) any medical conditions or previous surgeries?
Please provide more information of the medication being used if any.
Can you relate to any of the following?
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
What symptoms do you intend to treat using this medicine?
Please provide more information
If you are not the person who will use this medication, please enter their details here
If not describe in detail who the intended consumer is and how old he/she is.
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Please provide details of any recent or past medical history of note
Women only: Are you breast feeding?
Are you immunosuppressed due to disease or treatment?
Please list all your current prescription medication including any medication you buy over the counter...
Do you have any liver or kidney problems?
If yes, please provide details
Are you suffering from severe pain or discomfort?
Do you have any allergies?
If yes, please provide details - include medicines, food, materials or anything else
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
Do you currently have an infection of the outer ear?
Which signs and symptoms are you (or the person who will use this medication) currently experiencing?
You can select more than one option
How long have you (or the person who will use this medication) experienced these symptoms?
Please select your option
Have you (or the person who will use this medication) tried a different medicine to treat the symptoms before?
If yes, what medicine was it and was it effective ?
Does your problem only affect one ear?
Does pulling the middle of your earlobe toward the back of your head aggravate the pain?
Are you using Otomize to treat a recurrence of a swimmer's ear infection that was previously diagnosed?
Do you recognise yourself in any of the following scenarios:
You've had cholesteatoma (an abnormal growth of skin in the middle ear beneath the eardrum) from birth or as a result of repeated ear infections. You've experienced ear difficulties in the past that necessitated a visit to an ear, nose, and throat specialist. You have facial nerve palsy and suffer pain in your jaw when chewing or speaking (drooping face on the side of the lesion) You have a fever of more than 39°C, you are physically ill, and you have vertigo. You suffer from severe hearing loss. You have an infection that has migrated beyond your ear. You have a large amount of ear discharge.
Do you have a history of experiencing:
Ear infections that last a long time. Ear infections caused by fungi. Wax in your ears that needs to be removed with drops or ear syringing
Are you presently experiencing:
A grommet was installed. An eardrum that has been perforated (tympanic membrane) Dysfunction of the kidneys or the liver
Do you have a perforated ear drum or grommet fitted in the affected ear?
Have you had a serious reaction or intolerable side effects to neomycin sulfate, dexamethasone, glacial acetic acid or any medications before?
If yes, please describe the product and the reaction
Do you know of any ingredients in Otomize that you are allergic to or sensitive to?
Do you have an infection anywhere other than in the ear?
Do you have any open wounds or damaged skin in the affected ear?
Have you experienced a considerable amount of discharge from your ear or swelling of the ear canal?
Have you had persistent infection for the last 3 months?
Do you agree to the following?
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.