Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Who diagnosed your acne?GPDermatologistMyselfOtherWho diagnosed it and why do you think you have acne?What type of acne do you usually get?Whiteheads are small firm white bumps that can't usually be squeezed, and don't have pus in them. They are a type of comedone, like blackheads. 'Pustules' here refers to inflamed pus-filled spots.What type of acne do you usually get?Blackheads or whiteheads onlyA mixture of blackheads/whiteheads with mild redness and some pustulesMore redness and pustules than blackheads or whiteheadsLots of spots, redness and scarring, with or without deep skin boils/bumpsSomething elsePlease describe what kind of acne you getWhere is your acne?Face/neckShouldersChestBackOtherPlease tell us where else you have acneAre you currently experiencing any fevers, aching joints or lethargy with your acne?YesNoThese are symptoms specifically related to your acne. If you are experiencing a mild illness such as common cold or flu at the time of this request or related to another cause please select no.Are you currently using any acne treatment?YesNoWhat treatment are you using?Cream/gel aloneCream/gel with oral antibioticsOtherWhat's the name of you current treatment?How long have you been using this treatment?Less than 3 monthsMore than 3 months, but less than 6 months6 months or morePlease describe any changes you have noticed to your acne on this treatmentHave you been using your treatment as directed?YesNoPlease tell us how you have been using your treatment, including any breaks you have hadDo you want to stay on the same treatment?YesNoWhy do you want to change treatment?If you are considering a change in your treatment please ensure you have been using your current treatment as directed for the best effect. There are many different triggers to acne such as hormones, steroids, oily skin or hair products, cosmetics, certain medications and medical conditions. It's important to minimise your exposure to any triggers where possible which can help to reduce the chance of acne appearing, recurring or responding to treatmentHas a doctor ever prescribed anything else for your acne?YesNoPlease give us the name(s) of the treatment(s) you have been prescribedWhen did you last use any of these and for how long?Select Check BoxPlease tick to confirm that you give consent to upload photographs of your condition for the purpose of medical advice, and that you consent to us storing your photos securely in your medical records.What was your sex at birth?FemaleMaleThis allows our doctors to prescribe a suitable treatment for you. We are aware of and respect the fact that your gender identity may be different.Are you pregnant or breastfeeding?NoI'm pregnantI might be pregnant, I'm not sureI'm breastfeedingOtherPlease provide more detailsPlease upload two photographs of the affected area, making sure they're as clear as possible. Photos should include a piece of paper with the date written by hand. Click or drag a file to this area to upload. Photos should be clear and if possible taken from different angles. Try to get pictures that allow our doctors to know which part of your body it is, and compare the affected area with your normal skin. The handwritten date allows us to confirm the photos are yours and are recent. The paper should be held up somewhere within the photos you send of your skin.RiskThere is a risk with some acne medication of causing abnormalities to an unborn foetus if they're used by women whilst pregnant. These include medications we provide which contain a retinoid or adapalene (e.g. Differin, Aknemycin Plus or Epiduo). For this reason, if you are of child-bearing age and are sexually active with men, you must ensure you are using either a combined hormonal contraceptive pill with condoms, or have a contraceptive implant or coil in place. We would recommend you speak to your doctor about this before starting any acne medication to ensure you are not at risk of falling pregnant. Please tick to confirm you agree and understand.Please provide more detailsDo you have any conditions affecting your liver or kidney?YesNoPlease provide more detailsDo you have any other medical conditions, including skin conditions?YesNoPlease list all your medical conditionsAre you currently taking any medication, or have you recently finished a course of medication?YesNoPlease list the names and doses of all these medicationsWhat do you use these medications for?Are you allergic to any medicines or other substances? | For example, peanuts or soyaYesNoPlease tick all of the allergies that apply to youTretinoin or adapaleneBenzoyl peroxideAzelaic acidLymecyclineDoxycyclineErythromycinClindamycinLactosePenicillinPeanuts or soyaOther medicationsOther substancesNone of the aboveAre you unable to consume medication with either of the following in it?AlcoholGelatinNeither of the aboveAre you currently registered with a UK GP practice?YesNoI don't knowCan you tell us why you are not currently registered with a GP, or why you're unsure?I've only recently moved to the UKI've been removed from my practice list and not had a chance to register elsewhereOtherPlease provide more details.Checkboxes *I confirm the pictures attached are pictures of my own body *I fully understand the questions asked & have answered honestly & truthfully. I fully understand the side-effects of the treatment options, their effectiveness and alternative options & am happy to continue with my request. I confirm & agree that any treatment prescribed for me is for my personal use only. *Please tick here to signify that you have read, understand and agree to abide by our Privacy Policy. *NextWhat’s Your Birth Gender? *MaleFemaleName *FirstLastEmail * and When Have Phone *What’s Your Date of Birth? *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Select pharmacy for collection *674 Coventry Road, Small Heath, Birmingham, B10 0UU105 Barton Street , Gloucester, GL1 4HR267 Dewsbury Road, Leeds, LS11 5HZ41 Caldmore Green, Walsall, West Midlands, Walsall, WS1 3RWNationwide DeliveryYesPreviousNextDo you agree and consent to the following? You are completing this consultation for yourself and to the best of your knowledge. You will disclose any medical conditions, serious illnesses or operations you have had. You will disclose any prescription medications you are currently taking and agree to use only use one weight loss treatment at a time. You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy. Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life- threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation. *Please confirm you understandPrivacy Policy *I have read, understand and agree to AllCare Pharmacy Online Doctor's Privacy PolicySubmit
AllCare Pharmacy | Simplifying Healthcare