Start Your Acne Consultation

Please complete this confidential form. Our clinician will review and respond shortly.

Name

First Name

Last Name

Date of birth

YYYY

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

NHS Number

if known

Are you registered with a GP?

GP Surgery Name

Would you like us to notify your GP?

How would you describe your acne?

Where is your acne located?

Face

Back

Chest

More than one area

Please provide more information regarding location of acne (optional)

How long have you had acne?

Have you had any acne treatments prescribed by a healthcare professional before?

If yes, which treatments?

e.g. Benzoyl peroxide, antibiotics, topical retinoids

Have you ever previously taken oral isotretinoin (Roaccutane)?

Have you had any allergic reactions to any antibiotics or creams before?

If yes, please provide details

Are you currently pregnant/breastfeeding or trying to conceive?

Do you have a diagnosis of PCOS? (Polycystic Ovary Syndrome)

Have you experienced any signs of depression or mood changes linked to acne?

Consent & Declaration

I confirm the information I have provided is accurate.

I understand that treatment is at the prescriber's discretion.

I understand this service is not a replacement for in-person care

I am over 18 years of age.

I give permission to access my Summary Care Record for the purpose of carrying out a safe and effective clinical check as part of my consultation

⚠️ IMPORTANT NOTICE:

If you answered “Yes” to any of the following:

• Pregnancy, breastfeeding or trying to conceive

• Previous use of oral isotretinoin (Roaccutane)

• Severe acne or acne with signs of depression

Your case may not be suitable for online treatment. Please consult your GP or a dermatologist. A prescriber will review your answers and advise accordingly.

Start Your Acne Consultation

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