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Sex at Birth
Allergies to antibiotics (incl. doxycycline)?
If you answered Yes above, add details here.
List any medicines you take regularly.
History of liver or kidney disease?
History of oesophageal (food pipe) disease?
Currently pregnant or breastfeeding?
Have you been diagnosed with an STI in the last 3 years? (Note if you have not been diagnosed with an STI recently, we are unable to prescribe for you)
Do you currently have symptoms suggestive of an STI?
Examples: discharge, pain on urination, genital ulcers, sore throat, rectal pain
Are you regularly taking part in sexual behaviours where you are likely to be exposed to STIs?
https://www.nhs.uk/live-well/sexual-health/sex-activities-and-risk/ Please visit the link if you are unsure
When was your last sexual health screen?
Are you currently living with HIV?
If HIV-negative, are you currently taking PrEP?
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I confirm I have read and understood the DoxyPEP information and am requesting a prescription. I understand I must still attend regular sexual health screening. DoxyPEP is an unlicensed medication being used for an non-standard indication. This is a private service and I understand I will need to pay for Repeat Prescriptions and for the DoxyPEP itself. (£30 for a repeat prescription every 3 months, £25 for 50 Doxycycline 100mg Capsules) the initial prescription if approved will be for 3 months (3 x 50) that can be purchased individually.
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