Urinary Tract Infection (UTI) Form

If you have been advised by the surgery to submit a UTI (Urinary Tract Infection) form please complete this form.

Urinary Tract Infection (UTI)

Sex: *

If dropping a urine sample off, please use an appropriate sterile container and complete the following:

Women Only

Are you Pregnant? *
Please use this date format: DD/MM/YYYY

Urine Specimen

Please use this format dd/mm/yyyy.
Requested by: *
Reason: *


Please select the symptoms you have been having:
Please specify in days.



Do you have any allergies? *


Please select an option: *


I consent to receiving my results by text message if I am unobtainable by phone: *

What happens now?

Your sample will be tested if appropriate and the results passed to one of our clinicians. If your sample is positive for a urine infection, you may be issued with an antibiotic prescription if needed. You will be telephoned and informed about this by reception. It is possible that your sample will need to be sent to the laboratory for further analysis. It can take five days before the result is back from the laboratory. If your symptoms continue despite antibiotics, please contact the surgery and reception will advise you on the next steps.

Please note if your sample tests negative for infection and there are no documented symptoms of infection you will not be called. If you go onto develop symptoms or become unwell, please contact the surgery.