Request For Antibiotics For Simple Urine Infection (Female adults under 66 year old)

If you think you have a simple and mild urine infection and want to request antibiotics for this please complete this form.

If this is more serious or complicated needing further assessment by a clinician then please contacting the practice or 111/999 (as appropriate depending on the severity)

After 4pm you must phone the surgery as the request will not be processed until the next working day.

You must be registered with this practice to submit this form.

Request For Antibiotics For Simple Urine Infection (Female adults under 66 year old)

Request For Antibiotics For Simple Urine Infection (Female adults under 66 year old)

(Please use this format DD/MM/YYYY)
(Any responses we send will go to this email address)
My Symptoms include:
Discomfort as I pass urine:
My urine is cloudy:
I pass urine more at night:
Or
I need to pass urine more frequently at any time (which is new for me):
An urgent feeling that I need to pass urine (which is new for me):
I confirm that:
I think this is a mild urine infection:
I am NOT significantly unwell:
I am NOT pregnant:
I do NOT have any significant problems with antibiotics
I do NOT have complicated urinary/kidney problems
I have NOT seen blood in the urine:
I do NOT have complicated infections or repeated urine infections:
I am NOT vomiting:
I do NOT have fever:
I do NOT have abdominal pains or loin/kidney pains:
I do NOT have a catheter:
I do NOT have a significant medical problems that might alter the assessment

If you have been unable to confirm all the safety criteria above then please contact the practice when open or 111 service in the out of hours period as a clinician will need to assess you further before proceeding.

Nitrofurantoin/ Trimethoprim/ Pivmecillinam are commonly prescribed antibiotics for urine infections.

Once your request has been assessed, the clinician will contact you and this might be by text message to let you know that they are sending a prescription to your usual pharmacy. If you feel more unwell please seek urgent clinical advice instead.

The link below gives advice about how to help yourself and what to do if your symptoms change.

www.rcgp.org.uk/clinical-and-research/resources

Please note that if your symptoms are mainly vaginal itch or discharge instead, then consider that it might be a genital infection.

www.nhs.uk/conditions/vaginal-discharge/

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