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    Condition Questions

    Have you had this problem diagnosed by a professional before?

    Yes- I have seen a doctor, nurse or pharmacistYes- I have seen an aesthetics practitioner/ beautician/ cosmetics expertNo - I have diagnosed this condition myselfOther

    Why do you need treatment today?

    I’ve had this problem before and need a REPEAT prescriptionI’ve had this problem before but want to try a NEW medicationI’ve NOT had this problem before and want to try a medication to helpOther

    What symptoms do you have? Please select all that apply

    Dark patches or spots on your skin (usually brown or greyish)Symmetrical patches on both sides of your face (e.g., cheeks, forehead, upper lip)Dark spots that get worse with sun exposureUneven skin tone or discolorationPatches of pigmentation that appeared during pregnancy or after starting birth control pillsDark patches or spots that have lasted for months or longerWhite patches or lighter than your normal skin colourFlaky or scaly skin where the dark patches/ spots areNone of the aboveOther

    Do you experience any itching, pain, or discomfort with the dark patches?

    YesNoOther

    Are the patches only on your face, or do you have them on other parts of your body?

    Only on my faceOn other parts of my body tooOther

    Have you recently had any skin injury, inflammation, rash or acne in the areas where the dark spots appeared?

    YesNoOther

    Do you have any dark, thickened skin around your neck, armpits, or groin?

    YesNoOther

    When did the problems start?

    How quickly did the problem start?

    Suddenly (minutes)Quickly (hours)Gradually (days)Slowly (weeks)Very slowly (months)Over several yearsOtherI don't know

    Is it getting worse?

    NoYesOtherI don’t know

    How does the problem behave?

    It's always thereIt comes and goesOtherI don’t know

    How long does it last?

    MinutesHoursDaysWeeksMonthsYears

    Please explain:

    Have you been unwell in any other way recently or experienced any of the following symptoms?

    No- I have been wellI have been unwell recently due to another condition, illness or circumstanceTemperatureFeverNauseaVomitingNight sweatsWeight lossExcessive tirednessJoint pain/ swellingOther concerning symptomsI don’t know

    Please tell us more about how you've been unwell recently

    Please tell us more about your temperature

    Please tell us more about your fever

    Please tell us more about your nausea

    Please tell us more about your vomiting

    Please tell us more about your night sweats

    Please tell us more about your weight loss

    Please tell us more about your tiredness

    Please tell us more about your joint pain/swelling

    Please tell us more about your other concerning symptoms

    Does anything make it WORSE? Please select all that apply

    Sun exposureHeat e.g hot weather, hot showers Hormonal changes e.g pregnancy, birth control, hormone replacement therapy Skipping sunscreenUsing perfumed or scented skincare productsStressSkincare productsSunbeds or other UV light from indoor sourcesInconsistent skincare routineMedicationsOtherNone of the aboveI don’t know

    Does anything make it BETTER? Please select all that apply

    Daily use of sunscreenAvoiding sun exposure or wearing protective clothing
    e.g hats or sunglasses to protect your face
    Gentle skincare routine (avoiding harsh products)
    e.g using non-irritating cleansers
    Using hats or sunglasses to protect your face from the sunAvoiding heat exposure
    e.g avoiding hot showers, steam rooms
    Laser or chemical peel treatmentsDietOtherNone of the aboveI don’t know

    Have you already tried any of the following treatments?

    Sunscreens
    e.g. SPF 30, SPF 50, Sunsense, La Roche-Posay, Eucerin, Ultrasun

    Moisturisers
    e.g. Eucerin, Bioderma, CeraVe, Aveeno, Aloe vera, La Roche Posay Effaclar, Neutrogena

    Over-the-counter Melasma Products
    e.g Eucerin anti-pigment cream, The Ordinary, La Roche-Posay, Paula’s Choice, SkinCeuticals, The Inkey

    Prescription Melasma Treatments
    e.g Azelaic Acid, Retinoids (e.g. Tretinoin, Retinoic acid, Adapalene), Hydroquinone, Pigmanorm, Tranexamic acid tablets/cream

    Cosmetic procedures
    e.g. Chemical peels

    Laser/ Light/UV therapy

    Herbal/ Supplements/ Alternative treatments
    e.g Turmeric, Milk Thistle, Aloe Vera, Grape Seed Extract, Licorice Root Extract

    Other

    No - I haven't tried any treatments yet

    What is your biological sex?

    FemaleMaleOther

    Trans Female (Male at birth)Trans Male (Female at birth)

    Are you pregnant, breastfeeding or trying for a baby?

    Yes

    No

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Have you ever been diagnosed with any medical conditions?

    AneamiaAnxiety DisorderAsthmaAtrial Fibrillation (AF)Bipolar DisorderCancer (Past or Present)CholecystitisCOPDCrohnsDepressionEczemaEpilepsyFolic acid deficiencyMigraineMyasthenia GravisObsessive-Compulsive DisorderOsteoarthritisOsteoporosisPancreatitisPeripheral Vascular DiseasePsoriasisRaynaud’sRheumatoid Arthritis

    Gastric Reflux DiseaseGastric SleeveHay FeverHeart ArrhythmiaHeart Disease/ Heart AttackHeart FailureHigh Blood PressureHigh CholesterolInflammatory Bowel DiseaseIron deficiencyIrritable Bowel Syndrome (IBS)Kidney DiseaseLiver DiseaseStroke/ TIASurgeryThyroid DisordersType 1 DiabetesType 2 DiabetesUlcerative ColitisVitamin D deficiencySchizophreniaSjorgen’s syndrome

    None of the above

    Other

    Please provide details about your cancer diagnosis:

    Please provide details about any previous or upcoming surgeries:

    Please explain other medical conditions:

    Do you currently take any medications, vaccines, supplements, or recreational drugs?

    NoMedicationsOver the counter medications/ herbal medicationsSupplements

    Recreational drugsVaccinesOther

    Please tell us which medications you are currently taking:

    Please tell us what over-the-counter or herbal medications you are currently taking:

    Please tell us what supplements you are currently taking:

    Please tell us what recreational drugs you are currently using:

    Please tell us if you will be having any vaccines at the same time as using this medication:

    Please tell us what else you take:

    Do you have any allergies to any medications, supplements, herbs, chemicals, peanuts, soya or anything else we should be aware of?

    Yes

    No

    Please tell us more:

    Is there anything else you feel is important for us to know that would prevent us from safely prescribing for you?

    Yes

    No

    Photo Upload

    • If this is a new problem then we require at least one photo of it (max 6 photos) using your phone or digital camera.

    • Take a "far away photo" (from 1 meter away) to show the location and size of the problem.

    • Take a close-up photo (10-12 cm away) to show the details.

    • If appropriate please include a size reference (e.g. a coin or ruler) in your photo for scale.

    Upload Photo 1




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    GP Details

    By providing these details, you consent to us sharing relevant information with your GP if necessary for safety purposes, accessing your NHS Summary Care Record, or obtaining further details about your medical history.

    Do you understand and agree with the following?

    You are aware that if you have sensitive skin, it is important to start applying topical treatments such as retinoids, azelaic acid, or benzoyl peroxide every other day or once daily to allow your skin time to adjust and minimise irritation. A "purge" reaction, where breakouts temporarily worsen, can be normal and sometimes expected in the early stages of treatment. You can increase to twice daily if tolerated. If severe skin irritation occurs, you should reduce the amount or frequency of application, or temporarily stop using the product. Avoid contact with the eyes, mouth, and mucous membranes during application.

    You are aware that if your symptoms are not responding to treatment, you develop any worsening, new or severe symptoms, or you have any concerns or psychological distress, then you should see your GP or seek urgent care as soon as possible.

    You will read the patient information leaflet supplied with any medication we send you. If you have any allergies to any of the ingredients or any contraindications, you will not take the medication and contact a DigiDerm clinician for further advice. You have informed us of any allergies you have by completing the general health questions.

    You have informed us of any current or previous medical conditions you have by completing the general health questions.

    You are not pregnant.

    You agree that if needed, a DigiDerm clinician may contact you via email or telephone in response to this consultation form to offer advice and suggest treatments where necessary, or if they feel they need more information to make an accurate diagnosis or assessment of your condition.

    You agree that if, after reviewing your consultation, your skin problem is something we cannot treat or is not suitable for our service, then we will give you a full refund and suggest you visit your registered NHS GP for further advice.

    You are at least 16 years old and currently resident in the UK at the time of this consultation. This treatment is to be used only by you.

    You take responsibility to inform your own regular doctor/NHS GP of this online consultation and any treatments supplied, or any changes in your circumstances.

    The answers provided to the above questions are true and accurate to the best of your knowledge.


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