____Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.CheckboxesIf you are suffering from any symptoms that you wouldn't expect with indigestion, like breathlessness, chest pain or jaundice, or feel generally unwell, contact your GP urgently for help and advice. Please tick to confirm you do not have any of these symptoms at the moment.Why are you requesting treatment for indigestion today?I have symptoms of indigestionMy doctor has recommended it after having tests done (e.g. an endoscopy)My doctor has recommended it to protect my stomach from a regular medication I takeSome other reasonPlease select all that applyWhat symptoms of indigestion do you have?HeartburnAcid refluxBloating or fullness in your stomachFeeling sick or vomiting, especially after eatingBelching or burping more than usualPain or discomfort in your upper abdomenOtherWhat other symptom(s) do you have?Have you had an endoscopy?YesNoAn endoscopy is when you have a thin long tube with a camera on the end of it passed down into your stomach to have a look at what might be causing your symptoms.Some long-term medications can increase your risk of gastrointestinal bleeding. Have you been advised to take antacid medication because you are on any of these medications?Anticoagulant (like warfarin, apixaban or rivaroxaban)AspirinBisphosphonate (like alendronate or risedronate)Calcium channel blocker (like amlodipine, felodipine, verapamil or diltiazem)Non-steroidal anti-inflammatory drug (like ibuprofen, diclofenac or naproxenSelective serotonin re-uptake inhibitor or SSRI (like citalopram, sertraline or fluoxetine)Steroid (like prednisolone)Theophylline (a.k.a. Uniphyllin)OtherPlease give us more information about why you are requesting indigestion medication todayPlease tell us which medication you are currently taking that needs a PPI or H2RA alongside it.PPIs are proton pump inhibitors like Lansoprazole, Omeprazole, Pantoprazole and Esomeprazole. H2RAs are histamine-2 receptor antagonists like Ranitidine or Cimetidine.Do you suffer from any of the following symptoms?Unintentional weight loss (that is disproportionate to any lifestyle behaviours like dieting or exercise)Vomiting with visible bloodVomiting that is brown or looks like ground coffeeBlack stools that are thick and sticky (like tar), which can have a very strong, unpleasant smellA lump, growth or mass in your upper abdomenPain, discomfort or difficulty when you swallowA change in bowel habits (either unusual constipation or persistent/recurring diarrhoea)None of the aboveVomittingYou have indicated that you’re suffering from a symptom which could suggest a serious underlying issue and I would advise you to get in contact with your doctor urgently today, or go to A&E if you are acutely unwell. Please tick to confirm that you understand this.Have you been experiencing any of the following symptoms recently?Unusual shortness of breath, especially after exertion (like exercise or walking up stairs)Chest pain or tightnessPalpitations or irregular heart beatsJaundice (a yellow tinge to your skin or whites of your eyes)Dark coloured urineDiarrhoea, especially with oily or floating stoolsUnusually itchy skinRegular or unusual loss of appetiteNone of the above medication today of Do you have any of these rare hereditary conditions: fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency?YesNoDo you suffer from any liver diseases?YesNoPlease provide more details about your liver condition.Do you have any other medical conditions?YesNoPlease list all your medical conditions.Are you currently taking any other medication, or have you recently finished a course of medication?YesNoPlease list the names and doses of all these medications.What condition(s) do you take these medications for?Are you allergic to any medications or other substances?YesNoFor example, penicillin or lactose.Are you allergic to any of the following?PPIs (like lansoprazole, omeprazole, pantoprazole or esomeprazole)PenicillinPeanuts or soyaLactoseOther medicationsOther substancesP & SOur pharmacists source medication from a wide range of approved manufacturers to ensure we have a good supply available. Some manufacturers produce medication that isn’t suitable for people who suffer with peanut or soya allergies. Before starting your medication, it’s important to check the enclosed manufacturer’s leaflet to make sure the medication you’ve received is suitable for people with peanut or soya allergies. We also recommend checking with your local pharmacist.Please tick if you’d still like to proceed with your order.Are you able to take pills containing lactose?YesNoPlease provide more details about your other allergies.Please provide more details about your other allergies.Are you pregnant or breastfeeding?NoI'm pregnantI might be pregnant, I’m not sureI'm breastfeedingpregSimple over the counter antacids and alginates are recommended as first-line treatments in pregnancy, if symptoms are not improved by lifestyle changes (e.g diet).If you've tried these and still have symptoms, then the drug we offer is omeprazole. The manufacturer of omeprazole advises that it can be used in pregnancy, and is widely used in practice. But there is a lack of good quality evidence regarding safety, with some possible concerns about a small increased risk of congenital malformations, and a possible association with childhood asthma and allergy.If you're happy to proceed, we can offer this for you to use for the shortest time necessary. Please tick to confirm you understand.Are you currently registered with a UK GP practice?YesNoI don't knowCan you tell us why you are not currently registered with a GP, or why you're unsure?I've only recently moved to the UKI've been removed from my practice list and not had a chance to register elsewhereOtherPlease 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 *Please tick to confirm that you: fully understand the questions in this questionnaire and have answered honestly and truthfully fully understand the side effects of the treatment options, their effectiveness and alternative options, and are happy to continue with your requestconfirm and agree that any treatment prescribed for you is for your personal use only *Please tick here to signify that you have read, understand and agree to abide by our Privacy Policy. *NextWhat’s Your Birth Gender? *MaleFemaleName *FirstLastEmail *Phone *What’s Your Date of Birth? *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Select pharmacy for collection *674 Coventry Road, Small Heath, Birmingham, B10 0UU105 Barton Street , Gloucester, GL1 4HR267 Dewsbury Road, Leeds, LS11 5HZ41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RWNationwide DeliveryYesPreviousNextDo you agree and consent to the following? You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life- threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation. *Please confirm you understandPrivacy Policy *I have read, understand and agree to AllCare Pharmacy Online Doctor's Privacy PolicySubmit