Your Health

About You

1

Do you believe you have the capacity to make decisions about your own health; and that you do not require help to complete this consultation? *

2

What is your height? *

3

What is your weight? *

Your symptoms

4

Have you been diagnosed as having acne via a face to face consultation with a GP or dermatologist? *

5

Do any of the following apply to you? *

  • I have severe acne that present itself as large inflamed cysts or nodes
  • I have acne that is scarring my skin
  • I have tried 2 different antibiotics that have failed to clear my acne
  • I have tried topical antibiotics for 3 months without seeing any benefit
  • My acne is causing me severe psychological symptoms such as depression or anxiety
  • Please note: If any of the above apply, our pharmacy team may wish to contact you. Please respond to all queries in a timely manner, to avoid delays in processing your prescription. If you are experiencing a decline in mental health as a result of your acne, and you wish to be contacted for advice, please let us know when and how you would like to be contacted

6

Where is your acne? *

7

What best describes your acne? *

If you have nodes or cysts, which appear as large red boils that reside underneath your skin, you should visit your GP or dermatologist. Delaying treatment can cause scarring and topical antibiotics are unlikely to be effective.

8

Would you like to upload a picture of your acne? *

9

Are you currently using any treatment for acne? *

Your health

10

Are you pregnant, breastfeeding, planning pregnancy or at risk of pregnancy whilst taking this medication? *

Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period

11

Do any of the following apply to you? *

12

Have you had facial eczema, psoriasis, perioral dermatitis, or any other skin condition that affects the face within the last 6 months? *

13

Do you have any medical conditions? *

14

Do you have any allergies? *

Your Medication

15

Are you taking any medication? *

Agreement

16

Do you understand that you must discontinue treatment and seek medical advice if you experience severe redness, dryness, itching, or any other irritation? *

The initial skin redness and peeling with certain treatments such as Differin and Epiduo is known as retinization. This is the adjustment period when your skin adapts to the retinoid.This is common within the first few weeks of treatment, however, In the unlikely event that skin irritation is severe or not improving after 4 weeks, please see your GP or call our helpdesk. You may need to reduce the frequency of application, or temporarily stop using treatment, allowing your skin to recover before restarting again.

17

Are you aware that? *

  • Treatment should not be applied to sunburnt, broken or peeled skin; and that you should wait for your skin to heal before commencing treatment
  • Treatment may increase your skins sensitivity to the sun. do you understand the importance of avoiding exposure to natural or artificial light, using high protective sun factor and wearing protective clothing
  • When using treatment, avoid contact with the mouth, eyes, lips, inside of your nose and with skin that is abraded/eczematous; and if it does, you should rinse the area with luke warm water and seek medical advice
  • It may take anywhere between 2-8 weeks before you start to see a difference
  • Creams may be preferable for people with dry or sensitive skin and gels may be preferable for people with oily skin

18

Is there any additional information that you would like to provide, or any questions you have? *

19

Do you understand that? *

  • You should go and see your GP if your acne is not improving/getting worse, scarring your skin, causing you to feel depressed or causing side-effects
  • Applying too much treatment will not yield better results and can irritate your skin
  • It has been found that there is an association between acne and hormonal imbalances in some women. If other symptoms are present such as abnormal or excessive facial hair or irregular periods, then please consult with your doctor to further investigate any underlying conditions that might be causing your acne
  • Your treatment may contain ingredients which should not be used when pregnant or breastfeeding. It is advised that (if needed) you use an effective method of contraception while using your treatment. If you become pregnant you must stop your treatment immediately and contact your GP and advise our team.
  • It is recommended that you visit your GP or dermatologist for a face to face consultation if you have post acne scarring. We can supply you with treatment while you wait for an appointment
  • The majority of treatments for acne can cause the skin to become more sensitive to sunlight. Therefore, we strongly recommend you use an SPF of at least 30 while using acne treatment and avoid sunlamps and direct exposure in strong sunlight. It is important to choose the right sunscreen. We recommend a mineral-based sunscreen which should not aggravate your acne
  • We do not screen for any skin cancers. Any new, changing, or symptomatic (e.g., itchy, oozing, bleeding or inflamed) lesion or mole should always be examined by your doctor at a face to face consultation. This includes broken skin that doesn’t heal (an ulcer) within 4 weeks and any new or changing mark on your skin.
  • It is important that you inform us if you are planning to use other treatments, alongside what is being prescribed to you
  • It is important to avoid using other preparations on your skin whilst using treatment, such as medicated soaps, cleansers or scrubbing solutions and other preparations containing alcohol, astringents, spices or lime?

20

Do you confirm that? *

  • You are over 18 and the treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
  • You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • You are aware the decision about your treatment is for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's.
  • You will read the Patient Information Leaflet supplied with your medication. You should report any side effects and changes in your health and body to your GP, and via the Yellow Card Scheme
  • By continuing, you agree to our Terms & Conditions, Cancellation Policy and Privacy Policy