Male Patients Form 10

We’re Ireland’s online Medical Sick Certificate provider.

Male - Migraine Treatment

Put your details

Pharmacy Name*

Pharmacy Location*

Pharmacy EirCode*

What is your birth sex?

MALE

Please select which treatment you would like to apply for?

Did you have your first migraine in the last year?

YES NO

Did the symptoms of migraine begin after you turned 50?

YES NO

Who diagnosed you with migraines?

Your doctor or specialist Self diagnosis If other, please specify:

Do your migraines:

Make you weak on one side Give you visual loss or double vision Make you more uncoordinated or clumsy than normal Give you ringing in the ears or trouble hearing Make you unable to control parts of your body or speech None of the above If other, please specify:

You should see your GP or go to A+E if your migraine is worse than normal, you have had a recent head injury, your headache started suddenly or at the back of your head, or you have a fever - any of these features could be a sign of a more serious problem.

I understand

Do you have any conditions affecting your heart or circulation including heart attacks, angina (chest pain), heart failure, a stroke or mini stroke, or claudication (cramping pain in yours legs when you walk)?

NO If YES, please specify:

Have you had any health conditions including high blood pressure, liver or kidney disease, epilepsy or fits, phenylketonuria or any other health conditions?

No If YES, please specify:

Do any of the following apply to you:

You have high cholesterol A parent, brother or sister developed heart disease before they were 60 You smoke more than 10 cigarettes a day or use nicotine replacement therapies You are diabetic None of the above If other, please specify:

Are you currently taking any medication or have you stopped taking any medicines in the last two weeks, including any over the counter or herbal medicines?

NO If YES, please specify:

Are you allergic to any medicines or other substances (e.g peanuts/soya)?

NO If YES, please specify:

I fully understand the questions asked and have answered honestly and truthfully

I understand and have answered honestly and truthfully

I fully understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request.

I am happy to continue with my request

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

I confirm and agree that any treatment prescribed for me is for my personal use only.

Yes I confirm this treatment is for my personal use only.

Complete the prescription form below. If the doctor determines that an prescription is not appropriate for your case, you will be refunded.

EXPRESS SickCert: Prescription within 24hrs sent via email. 29.99 EUR

*This will be reviewed and signed by an Irish doctor and is emailed to you within 24 hours.

RECOMMENDED: Prescription will be prioritised in the queue and sent via email. 24.99 EUR

*This will be reviewed and signed by an Irish doctor, sent via email and your request will be at the top of the request queue.

EMAIL: Prescription will be sent via email within 2-3 working days 19.99 EUR

*This will be reviewed and signed by an Irish doctor and sent via email, usually delivered within 2-3 working days.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).

I CONFIRM I DO NOT CONFIRM

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Male Patients Form 10

Male - Migraine Treatment

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