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Repeat Script
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Letters
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Health Declaration
Covid19
OnlineDoc Treatment
Angular Cheilitis Treatment
Only
€
23 per Script
Angular Cheilitis Treatment
First Name
Last Name
Date Of Birth
Email
Phone Number
Address
Please specify your gender:
*
Male
Female
Please Upload Photo(s) of your current issue. (Optional)
Upload File
Upload supported file (Max 15MB)
How long do you have it
Which one of the below signs do you have? Please select
*
Required
Cracking
Crusting
Bleeding
Blisters
Maceration (soggy, lighter-colored skin)
Redness
Swelling
Non of them
Other (Please Specify)
If Others, Please specify:
which one of the following trigger factors do you have? Please select
*
Required
Eczema around your mouth
Dentures that don’t fit
Drooling during sleep
Fungal or yeast infections in the mouth, such as thrush
Misaligned teeth
Skin allergies
Sucking on a thumb or a pacifier.
Wearing a face mask.
Non of them
Other (Please Specify)
If Others, Please specify:
Have you recently undergone blood tests?
*
No
Yes, (If Yes, Please Specify the abnormal results here)
If Yes, Please specify:
What else would you like to inform our doctors about your current issue?
Do you plan to become pregnant, breastfeed, or are you pregnant? (For Females)
*
No
Yes
If Yes, Please specify:
Do you have a significant past medical or surgical history?
*
No
Yes
If Yes, Please specify:
Are you allergic to any medication or any other substance?
*
No
Yes
If Yes, Please specify:
Please provide the name and address of the pharmacy where you'd like to pick up your medications.
I confirm that the answers I have provided for the above questions are true and accurate to the best of my knowledge.
*
I Confirm
I Do Not Confirm
I confirm and agree that any treatment prescribed for me is for my personal use only.
*
I Confirm
I Do Not Confirm
I fully understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request.
*
I Confirm
I Do Not Confirm
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