Medical Assessment for Acne

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you 18 years of age or older?

Yes

We are unable to supply you with treatment. Please consult your GP or doctor.

Please complete this question.

Do you have mild or moderate acne?

Yes

These products are not suitable for you, if you have severe acne. You would be better consulting your GP.

Please complete this question.

Your Health

Are you allergic to any of the following:

Adapalene
Azelaic Acid
Benzoyl Peroxide
Clindamycin
Tretinoin
Propylene Glycol

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Are you female and between 18 and 55?

Yes

Some acne treatments can cause birth defects. You must use effective contraception whilst using acne treatments. Acne treatments should be discontinued at least one cycle prior to pregnancy. If you forget your contraception you should stop using your treatment and if you fall pregnant whilst using an acne treatment, stop it immediately and inform your GP.

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Are you pregnant, planning on becoming pregnant, or breastfeeding?

Yes

Many acne products are not suitable for use in pregnancy as there is a risk of birth defects.

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Do you have inflammatory bowel disease, eg ulcerative colitis, crohns disease, or any other form of colitis?

Yes

We can provide you with treatment, but products containing clindamycin will be unsuitable for you.

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Your Medication

Are you taking oral antibiotics?

Yes

We can provide you with treatment, but products containing topical antibiotics are unsuitable for you.

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Are you using any other treatments for acne?

Yes

We do not recommend using two acne products at the same time

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Agreement

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, you start new medication and/or 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
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

Please complete this question.

Do you understand if your acne gets worse or starts to cause scarring, you must see your GP?

Yes

You must see your GP if your condition gets worse.

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Do you understand some topical acne treatments can make your skin more sensitive to sunlight (photosensitivity)? You should avoid sunlight and sunlamps while using topical acne treatments and take care to use sunscreen and cover in protective clothing if sunlight exposure is unavoidable. Do not apply acne products to sunburn

Yes

It is advised to avoid exposure to sun lamps and direct sunlight during treatment, since this medicine can make your skin more light sensitive. Contact customer support for further information.

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Do you understand that it can take 4-8 weeks of treatment before beneficial effects are seen?

Yes

It often takes 8 weeks or more for treatment to work. For more information contact our helpdesk.

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Do you understand that most people will experience some skin redness and peeling during the first few weeks of treatment? If your skin becomes irritated, you may need to use an oil-free moisturiser, use your treatment less often, or stop using it for a short period to allow your skin to recover and then re-start treatment. If irritation persists or symptoms are severe, stop using the medication and contact our help desk or your GP.

Yes

You must agree to this before continuing. If you need assistance contact customer support.

Please complete this question.

Do you understand that this medicine must not come in contact with eyes, mouth, mucus membranes, or eczematous/ broken/ sunburned skin, and that if it does by accident you should seek medical advice?

Yes

This medication can cause irritation to the eyes or mucous membranes (e.g. lips and gums), and if it comes into contact with either you should seek medical advice.

Please complete this question.

Do you understand that you should use your treatment once a day, after washing your face with a mild cleanser and fully drying?

Yes

You must agree to this before continuing. If you need assistance, contact customer support.

Please complete this question.

Medical Assessment for Acne

To help us supply you with the most suitable treatment, please complete this online consultation.

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