Please answer the following questions about yourself (or for the person who will take this medicine). If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860

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If yes please provide more details


Please describe in detail who the intended user is and answer all questions on their behalf


Please select your option

Male
Female
Transmale (Born a female)
Transfemale (Born a male)


If yes, please provide details

If yes is this Type I or II?

If yes please provide more details

If yes please provide more details

e.g. I live with 2 people and a cat, am a painter and decorator

 

If Yes please provide more details on how many units per week and usually when consumed

If yes please provide more details

If yes please provide more details

If yes please provide more details




Please answer the following questions to help us understand more about your symptoms and health

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Please select as many symptoms needed
Itching/ irritation
In the ear canal there is pain or discomfort
An ear canal discharge that is watery
The skin surrounding the exterior of the ear and around the canal is dry and flaking
Due to swelling and inflammation the ear canal becomes obstructed
Hearing impairment in the affected ear

Please select your option

A week
A month
More than a month
Less than 1 day
1-2 days
More than 3 days

If yes, what medicine was it and was it effective ?





  • 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.


  • 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

If yes, please describe the product and the reaction









Please confirm your agreement to our prescribing partnership

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  • You will read the patient information leaflet supplied with your medication. The treatment is solely for your use (or the person you have completed this for and with their consent). 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.

We advise you to share this treatment with your doctor so they can update your medical records. Please provide their address if appropriate.