Llantwit Doctors – Llantwit Major, Rhoose and St Athan

Suspected Urinary Tract Infection Online Form

Please only use this form if you are female and aged between 18-65 years old.

Please do not use this form if you are pregnant.

Full Name:

Date of Birth:

Age:

Email Address

Mobile Number for text message from GP:

Do you have any allergies? (If yes, please specify)

Are you pregnant?

Yes

Are you breastfeeding?

Yes

Symptoms

It is important you select as truthfully as possible so we can provide you with the correct advice and treatment.

Please select which symptoms you are experiencing?

Burning or stinging on passing urine (Dysuria)

Passing urine more often than usual (Frequency)

Discomfort in the lower abdomen

Needing to rush to the toilet (Urgency)

Passing more urine than normal (Polyuria)

Blood in urine (Haematuria)

Vaginal discharge

Flank pain

Fever (Temperature above 38oC)

All fields on this form are mandatory, please complete to the best of your knowledge. By using this form, you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your details.

You will be contacted at some point the same day, please ensure the mobile number you have provided is correct

Suspected Urinary Tract Infection

Suspected Urinary Tract Infection Online Form

Symptoms

Further Information