2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3582 0000
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Acid Reflux / Heartburn Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Do any of the following apply to you?

    • Aged 45 years or over:
    • With new onset of symptoms within the last year
    • Where symptoms are worsening or changing
    • People of any age with heartburn where there is
    • Unintentional weight loss
    • Anaemia
    • Difficulty or pain on swallowing
    • Vomiting, particularly if there is blood in the vomit
    • Previous gastric ulcer or surgery
    • Jaundice
    Please ring the surgery to book a telephone consultation with the GP

    Yes

    No

    3. Are you aware all acid symptoms should settle with 5 or fewer days of treatment?

    • Omeprazole 20mg daily for 5 days should settle all symptoms for at least a few days.
    Omeprazole 20mg daily for 5 days should eliminate all symptoms. Symptoms which persist require investigation by a GP.

    Yes

    No

    4. Are you aware if symptoms are not controlled by taking Omeprazole, that a GP should be consulted?

      If symptoms are not controlled by taking Omeprazole, a GP should be consulted. You can change your answer to 'Yes' and continue.

      Yes

      No

      5. Are you aware worsening or changing symptoms require a review by a GP?

        If symptoms are changing or worsening a GP should be consulted. You can change your answer to 'Yes' and continue.

        Yes

        No

        6. Are you planning to order Omeprazole and take any of the following?

        • Please answer 'No' if order Zantec (ranitidine)
        • Atazanavir - for HIVKetoconazole, itraconazole or voriconazole - for fungal infections
        • Diazepam for treat anxiety, relax muscles or in epilepsy
        • Phenytoin - for epilepsy
        • Medicines that are used to thin your blood, such as warfarin
        • Digoxin - used for heart problems
        • Tacrolimus - in organ transplants
        We can not supply you with Omeprazole. Please discuss with your GP.

        Yes

        No

        7. Do all of the following apply to you?

        • I will read the patient information leaflet supplied with my medication.
        • The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
        The conditions must apply for you to be able to use this service.

        Yes

        No

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