Online UTI PFS Form

1

Do you live in England?* This field is required.

YESNO

2

Name* This field is required.

First Name

Last Name

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Email* This field is required.

example@example.com

5

Address* This field is required.

Street Address

Street Address Line 2

City

County

Post Code

Country

6

Gender* This field is required.

Male

Female

Prefer not to say

7

Please select your age category* This field is required.

Under 16 years of age

17-64 years of age

Over 64 years of age

8

Is there a possibility that you may be pregnant?* This field is required.

YESNO

9

Do you use a urinary catheter?* This field is required.

YESNO

10

How often do you suffer a urinary tract infection?* This field is required.

This is my first time

2 episodes in the last 6 months

3 episodes in the last 12 months

Other

11

To further help you we will need to register you as our pharmacy patient and record your personal details. This information, and any advice/ treatment, may also be shared with your GP if deemed necessary by the Pharmacist.* This field is required.

Yes I understand and am happy to continue

12

Date