Asthma Treatment

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If you are suffering from acute breathlessness, wheeze or chest tightness, contact 999 for help. Please tick to confirm you do not have any of these symptoms at the moment.
This is not an emergency service for asthma and is not intended to replace regular reviews and monitoring with your GP. Please tick to confirm you understand this and that you agree to see your GP for an asthma review at least once a year.

Have you been formally diagnosed with asthma? *

The diagnosis needs to have been made by a doctor, usually your GP or a hospital specialist.

Why do you need asthma treatment? *

I have COPD
Other reasons

If you have COPD please complete an assessment through our COPD service to ensure that we can provide the appropriate advice and treatment.

Please provide more details: *

Why are you requesting treatment today? *

My inhaler has run out
I need a spare inhaler
To replace a lost or broken inhaler
Other reasons

Please provide more details: *

Do you usually use a reliever inhaler for your asthma? *

A reliever inhaler is one that you use when you have asthma symptoms, for example a blue inhaler, salbutamol inhaler or Ventolin inhaler.

What is the name of your reliever inhaler?

Salbutamol inhaler (generic)
Ventolin inhaler
Other

What is the name of your inhaler? *

How long would a reliever inhaler normally last you before it runs out (assuming it doesn’t get lost or broken)? *

less than a month
1 to 2 months
2 to 6 months
more than 6 months

Why don't you usually use a reliever inhaler for your asthma? *

Do you usually use a preventer inhaler for your asthma? *

A preventer inhaler is one which you use on a daily basis to prevent your asthma getting worse, and normally contains a steroid in it. Examples include Clenil, Qvar, Symbicort, Seretide, Fostair or Pulmicort.

Please tell us names of any inhalers you use, including the number or strength on the device: | For example: Clenil 100. *

How many times do you use this every day? For example: 2 puffs, twice a day. *

Do you use any other treatment for your asthma? | For example: tablets such as Montelukast. *

Please provide more details: *

In the last month, how often have you been woken up at night by your asthma? *

Rarely or never
One or more nights per week

In the last month, how often have you had your usual asthma symptoms during the day? *

Rarely or never
Less than 3 days a week
3 or more days a week

For example: cough, wheeze, shortness of breath, chest tightness.

In the last 12 months, have you been to hospital as an emergency because of your asthma? *

Have you seen your GP about your asthma since you were in hospital? *

When did you last see your GP or nurse for a review of your asthma? *

in the last 12 months
more than 12 months ago
I don't know

It is recommended that you have an asthma review with a doctor or nurse every 12 months.

Are you pregnant? *

Have you seen your GP or asthma specialist for a review since becoming pregnant? *

Do you have any other medical conditions? For example: heart disease or diabetes. *

Please provide more details: *

Are you currently taking any medication, or have you recently finished a course of medication? *

Please list the names and doses of all these medications: *

What do you use these medications for? *

Are you allergic to any medicines or other substances? For example: peanuts or soya. *

Please select all of the allergies that apply to you: *

Penicillin
Peanuts or soya
Lactose
Other medications
Other substances

Are you able to take inhalers or medication containing lactose? *

Please provide more details:

Are you currently registered with a UK GP practice? *

Yes
No
I don't know

Can you tell us why you are not currently registered with a GP, or why you're unsure? *

I've only recently moved to the UK
I've been removed from my practice list and not had a chance to register elsewhere
Other

Please remember that you must make sure to provide GP details next time, otherwise we might not be able to accept your order request.

Please provide more details: *

Checkboxes *

I fully understand the questions asked and have answered honestly & truthfully. I fully understand the side-effects of the treatment options, their effectiveness and alternative options & am happy to continue with my request. I confirm & agree that any treatment prescribed for me is for my personal use only. *
Please tick here to signify that you have read, understand and agree to abide by our Privacy Policy. *

Your request *

Ventolin Evohaler
Salbutamol CFC Free Inhaler
Clenil Modulite
Fostair 100/6 MDI
Pulmicort Turbohaler
Qvar Aerosol
Seretide Accuhaler
Symbicort Turbohaler
Telephone Consultation with a Doctor (does not include prescription medication): (Only Phone consultation)

What’s Your Birth Gender? *

Male
Female

Name *

First

Last

Email *

Phone *

What’s Your Date of Birth? *

Select pharmacy for collection *

674 Coventry Road, Small Heath, Birmingham, B10 0UU
105 Barton Street , Gloucester, GL1 4HR
267 Dewsbury Road, Leeds, LS11 5HZ
41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RW

Nationwide Delivery

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Gloucester

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