Acne Treatment Consultation

Personal Information & Acne Details

Please provide your details accurately

Name *

First

Last

Date of birth? *

YYYY

Phone number? *

Address? *

Email *

Please specify your gender? *

MALE FEMALE

Please specify which prescription you are looking for? If not sure please select don't know. *

Which healthcare professional diagnosed you with Acne? *

GP DERMATOLOGIST ONLINE DOCTOR IF OTHER

Which treatment you are currently using for your acne? *

NO TREATMENT YES, SPECIFY BELOW

Is your current medication keeping your acne under control? *

YES NO

Please specify the area of your body which is affected by acne? *

FACE FACE & SHOULDERS FACE, SHOULDERS & BACK ALL AREAS OTHER

Please specify the reason you are requesting the above mentioned medicine? *

ALREADY USING IT USED IN THE PAST SUGGESTED BY DOCTOR SUGGESTED BY FRIEND OTHER

Are you pregnant, planning for pregnancy in next few months or are you breast feeding? *

YES NO N/A - I AM A MAN

Medical History & Consent

Please provide your medical information

Do you have any past medical history of hypertension, heart attacks, angina, heart failure, stroke or TIA, or claudication? *

NO IF YES, PLEASE SPECIFY

Do you have any past medical history of liver, kidney disease, epilepsy or any other medical and surgical conditions? *

NO IF YES, PLEASE SPECIFY

Are you currently taking any prescription, non prescription medication or any illegal drugs, herbal medication? And have you taken any medication recently in last two weeks? *

NO IF YES, PLEASE SPECIFY

Do you have any past medical or surgical history? If yes please specify below. *

Are you allergic to any medication or any substance? *

NO IF YES, PLEASE SPECIFY

Please specify which of the following applies to you? *

Select all that apply:

Do you have high cholesterol Your family members have developed heart disease before they were 60 Do you smoke more than 10 cigarettes a day or use nicotine replacement therapies You are a patient of diabetes None of the above

I understand the side-effects and effectiveness of the above mentioned treatment and I am giving consent to continue with my request. *

I am happy to continue with my request

I am confirming that the treatment prescribed above will be for my personal use. *

Yes I confirm this treatment is for my personal use only.

Please specify the name of preferred pharmacy where you want to collect your prescription/medications? *

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge. *

I confirm

Checkout

Review your details and complete payment

Consultation Summary

Acne Consultation Fee

GP Review + Prescription

€25.00

Your payment is processed securely via Stripe. We never store your card details. If the prescription is not appropriate for you, a full refund will be issued.