1
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?

NoYes

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?

NoYes

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

NoYes

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

NoYes

Please provide more detail.

Do you suffer from any allergies?

NoYes

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?

NoYes

Please provide more detail.

2
Medical Questions

Are you requesting treatment for Impetigo?

NoYes

Are you requesting treatment for Eczema and/or Psoriasis?

NoYes

Please describe the symptoms you are experiencing

Does the rash consist of vesicles which weep and form yellow/brown crusts?

NoYes

Please provide more information below.

Is the rash limited to a few lesions on one area of the body?

NoYes

Please provide more information below.

Please state the exact area which is affected.

Note: entering just "face" will result in your assessment being rejected or delayed. You have to provide as much detail as possible.

Is the affected area inside the nostril?

NoYes

Have you been treated for Impetigo within the last 3 months?

NoYes

Please provide more information.

We would strongly advise that you upload a photo of your skin condition as this will prevent delays in your order being dispatched, especially if:

You have not tried any other streoid or moisturiser creams
You are ordering a topical antibiotic such as FUCIDIN, FUCIDIN H and FUCIBET
Have not been previously diagnosed
You do not moisturise regularly
You are requesting this medication without being diagnosed

*(Optional Question however uploading an image will aid in getting your order to you quicker as it will allow for a clearer idea of suitability of your the treatment)*

Upload Image

Are there other skin conditions in the same area?

NoYes

Please provide more information

Have you previously been diagnosed with Eczema or Psoriasis by a healthcare professional?

NoYes

Please provide more information.

Are you currently experiencing a flareup in your Eczema or Psoriasis?

NoYes

Does this incident of Eczema/ Psoriasis differ in any way to when it has been previously diagnosed?

NoYes

Please provide more information.

Which parts of your body require treatment with this product?

Please describe the area that requires treatment, including the location on the body and appearance.

How long have you suffered from Eczema or Psoriasis?

Have you used any other creams or ointments to treat the same skin condition?

If "Yes" please tell us what they were and if they were effective or not.

NoYes

Please provide more information.

Do you regularly moisturise your skin (especially areas that are likely to be dry or cracked)?

If "Yes" please tell us what other creams you use or have used previously.

NoYes

Please provide more information.

Did you know that you should routinely moisturise patches of eczema up to four times daily using an emollient cream or ointment.

You should be aware that you must see a doctor about new rashes, worsening rashes and rashes not responding to treatment.

3
Consent

Would you like us to notify your GP of the treatment you chose to order today?

NoYes

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:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

NoYes

Sorry we can't offer you this treatment, please contact your GP.

If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Assessment

Trust Pilot

Medical Questions

2
Medical Questions

3
Consent

Confirm treatment selection

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Assessment

Trust Pilot

Medical Questions

2Medical Questions

3Consent

Confirm treatment selection

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Medical Questions

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Consent