Asacol/Mesalazine

* Have you ever been prescribed this item?

* How long ago were you first prescribed this medicine

* When were you last prescribed this item?

* What was the prescribers directions/dosage? (For example, Use three times a day)

* When did you last have a review of this medication with your normal doctor?

* Were any issues raised at your last review?

* Please provide details below

* Are you currently under the care of a clinician who monitors your treatment with this medicine?

* Why are you ordering this item from Pharmacy Planet today?

* Do you suffer from any of the following condition?

• Unexplained weight loss
• Difficulty swallowing
• Liver or kidney disease
• Severe or persistent diarrhoea
• Black stools (blood stained fasces)
• Vomiting food or blood
• Sugar intolerance
• History of gastric ulcers or surgery
• Persistent loss of appetite
• Cancer
• Porphyria

* Please provide details below

* Do you undertake regular blood tests to monitor your body's response to this medicine?

* Please confirm that you will consult your usual doctor immediately if you experience any of the following symptoms:

• Fever, sore throat, mouth or lip ulcers, spots underneath your skin anywhere on your body, including the genital and anal regions, become very pale, swollen ankles or have unusual bleeding (e.g. unexpected nosebleeds or bleeding gums)
• Skin rash with flaking, boils or sore lips or mouth
• Bruising more easily or suspect blood abnormalities
• Problems with kidney function

* Please confirm your understanding and acceptance of the following:

• You are ordering the medication for yourself.
• You have answered the questions truthfully. 
• Before taking the medicine you will read the enclosed patient information leaflet and follow the guidance issued by the manufacturer.
• If you are purchasing this item for use in the eye, and you wear contact lenses, you will follow manufacturers guidance regarding concurrent use. 
• You will contact your GP/Doctor if you suffer from any unwanted side effects or if your condition is deteriorating.
• You give permission for Pharmacy Planet to access your summary care records, if clinically necessary for patient safety.
• All images of products are illustrative only
• Decisions regarding treatment are for joint consideration between yourself and the prescriber. However, the final decision will be the prescribers.