Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare?

Are you aged between 18 and 65?

If you are of child bearing potential, are you using effective contraception?

Have you been diagnosed by your GP or GUM clinic with Genital Warts?

Are you experiencing any of the following?

• unintentional weight loss
• blood in your urine or stools
• pain when urinating
• urinary tract infections (UTI)
• night sweats
• fever
• bleeding from the anus or urethra
• discharge/ fluid from the wart
• discharge from the penis or vagina
• swollen lymph nodes
• abnormal urine flow
• change in the appearance of your warts since they were diagnosed by a medical doctor
• warts located internally (inside the urethra, vagina, cervix, rectum or anus)
• anal warts
• open, sores or wounds, broken skin or ulcers near your warts including broken skin following surgery
• bleeding between periods or after sex (women only)
• warts on foreskin
• you have had your current outbreak for more than 18 months
• your warts cover an area larger than 4 cm2

Do you have an allergy (hypersensitivity) to medicines containing imiquimod or podophyllotoxin?

Are you breastfeeding or pregnant or possibly pregnant?

Have you been diagnosed with any of the following?

• Liver problems
• Kidney problems
• Immunodeficiency/ immunocompromising conditions (eg. HIV, autoimmune conditions/ diseases)
• Abnormal blood count
• You have received an organ transplant
• Your warts cover an area larger than 4 cm2
• Reduced haematologic reserve
• Any serious medical condition which may require immediate hospitalisation

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Do you understand that it is best practice to maintain genital hygiene and avoid sexual contact whilst on treatment, but if you do have sexual contact, please wear a condom?

Do you understand that you should return to your GP or GUM clinic for an examination of your genital warts if they do not improve after 4 weeks of treatment with podophyllotoxin (Warticon) or 16 weeks of treatment with imiquimod (Aldara)?

Do you agree to the following?

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• 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.
• I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
• 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 are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.