About You


Please provide your weight.



Please provide your height.


Do you smoke or drink?

Do you take any medication whether prescribed, over the counter, herbal/alternative or partake in any recreational drug use?

Do you have any allergies?

Have you been advised to avoid strenuous exercise?

Are you able to walk 3 miles or climb a set of stairs without pain in your chest?

Do you have any history of symptoms of anxiety or depression?


About your symptoms

Are you pregnant, breast-feeding or planning a pregnancy?

Do you have, or have you had any kidney/liver problems?

Are you due to have an endoscopy, urea breath test or Chromogranin A blood test?

Do you have osteoporosis?

Do you have a magnesium or vitamin B12 deficiency?

Have you had a previous oesophago-gastroduodenoscopy (procedure used to examine the inside of your body with a tiny camera)?

Have you had a stomach ulcer or stomach surgery in the past?

Have you been told by your doctor that you have an intolerance to any sugars? E.g. fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency

Do you get stomach pain?

Do you need to take a non-prescription indigestion or heartburn remedy treatment every day?

Have you been taking treatment continuously for reflux or heartburn for 4 or more weeks?

Have you had a reaction to esomeprazole or medicines containing other proton pump inhibitors? (e.g. lansoprazole, omeprazole, pantoprazole)


GP Details

Would you like us to inform your GP of your treatment?
We recommend informing your GP surgery of any treatment that you are taking to keep your medical records relevant and up to date



Do you agree to the following?
  • You have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and interactions with Quick Meds. Any incorrect responses or deliberate acts to misinform may be hazardous to your health.
  • You agree to the terms and conditions, privacy policy and terms of use.
  • You will familiarise yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone.
  • You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way.
  • You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health and appropriateness in mind.
  • You agree to the terms and conditions, privacy policy and terms of use.