Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Do you currently suffer from Rosacea?
Please provide more information as to why you are requesting this treatment
Has a GP or a specialist diagnosed you with Rosacea?
How long have you suffered with Rosacea?
Please describe your current symptoms in as much detail as possible (flushing, persistent redness, visible blood vessels, papules, pustules and thickened skin)
How long do you believe you have suffered with Rosacea?
Please describe your symptoms in as much detail as possible (flushing, persistent redness, visible blood vessels, papules, pustules and thickened skin)
Do you suffer from any other symptoms?
Please provide us with more details regarding your Rosacea symptoms
Please tell us which areas of your body are affected by Rosacea.
Give as much detail as possible, for example, chin, cheeks and T-Zone. Please do not just say "face"
Do you suffer from any other skin conditions such as perioral dermatitis, cutaneous epithelioma, eczema and psoriasis?
Please provide more information including any other steroid creams you use on your face to treat these conditions e.g Betamethasone (betnovate), Clobetasone (eumovate) or Hydrocortisone
Do you suffer from any of the following symptoms:
Can you tell us more about your symptoms, for example:
Do any of the following statements apply to you?
Does your Rosacea cause you any psychological or social problems?
Please provide more details
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
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