Order Ear Infection Prescription Medicine

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No

Does your condition just affect the one ear?

Yes
No

What are your current symptoms?*

Itching
Pain or discomfort in the ear canal
A watery discharge from the ear canal
Dry flaky skin around the outside of the ear and along the canal
The ear canal becoming blocked due to swelling and inflammation
Loss of hearing

Select one or more answers

If you pull the middle of your earlobe toward the back of your head does this make the pain worse?

Yes
No

Are you using Otomize to treat a recurrence of an infection previously diagnosed as swimmer's ear?

Yes
No

Have you ever suffered from:

Yes
No

Chronic ear infections, fungal ear infections or wax in your ears that requires drops or ear syringing?

Please provide more details

Does any of the following apply to you:

Yes
No

You have cholesteatoma (an abnormal growth of skin in the middle ear behind the eardrum) either from birth or due to chronic ear infections
You have had problems with your ears in the past which have required you to see an ear, nose and throat specialist.
You have discomfort in the jaw when chewing or speaking
You have facial nerve palsy (drooping face on the side of the lesion)
You have a temperature over 39°C
You feel physically unwell
You are suffering from vertigo
You have extensive hearing loss
You have an infection spreading beyond the ear
You have extensive discharge from the ear

Do you currently have:

Yes
No

A grommet fitted
A perforated eardrum (typanic membraine)
Kidney or liver dysfunction

Are you allergic to or sensitive to any of the ingredients in Otomize?

Yes
No

Are you aware that:

Yes
No

If your symptoms are not improving after 3 days then you need to see your GP
Treatment with Otomize should not be continued for more than 7 days
If your symptoms get worse before or during treatment that you will see your GP
Stop using Otomize and see your GP if irritation or rash occurs
The ear should be kept dry throughout treatment, including whilst washing

Are you currently taking any medication?

Yes
No

Please provide details of any medication you are currently taking

Do any of the following apply:

Yes
No

You have any medical conditions that you have not already mentioned
You have, or previously had, any mental health problems that required specialist mental health support or hospitalisation
You have had majory surgery
You have heart problems or have had a stroke
You have decreased kidney or liver function

Please provide more information

Do you have any allergies?*

No known allergies
Nuts and/or soya
Lactose
Other (please specify)

Select one or more answers

Other (please specify)

Do you agree to the following?

Yes
No

You will read the patient information leaflet (provided with your medication or by following the relevant link)
The treatment is solely for your own use
All the information you have provided is accurate. You understand our prescribers can only base decisions on the information provided and that incorrect information can be detrimental to your health.
We need to ensure that this medicine is suitable for the person it is intended for. Therefore may be required to contact you by phone/video call, If we are unable to speak to you when required your order may be delayed.
I consent to receive treatment from My Pharmacy, and confirm that I have the mental capacity to do so. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always rest with the prescriber and is subject to approval. If treatment is not suitable, you will be signposted to another point of care.
You will seek medical advice if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
You will inform your GP with regards to this prescription (It is best practice to inform your GP of any private treatment you receive. All treatment is completely confidential).

Terms & Conditions

I confirm that I am over 18 and I agree to the Terms and Conditions

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Otomize Ear Spray 5ml

Ear Infection

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