Are you taking any of the following medication?

Beta-blockers Cimetidine Nitrofurantoin Other local anaesthetics Phenytoin or phenobarbitol Sulphonamides e.g Co-trimoxazole

Do you agree to the following?

You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. The treatment is solely for your own use You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Are you allergic (hypersensitive) to lidocaine or prilocaine, or other similar local anaesthetics?

Do you suffer from any of the following:

Anaemia Methaemoglobinaemia (problem with blood pigment levels) Glucose-6-phosphate dehydrogenase deficiency (rare inherited medical condition affecting the blood)

Are you breastfeeding, pregnant or planning to become pregnant?

Do you have any cuts, rashes, eczema, bleeding or scabs, or sore skin where you intend to apply the cream?