Acne Consultation Form

    How long have you suffered with acne?

    What type of skin do you have? (eg- oily, dry, sensitive, combination)

    What areas of your body are affected by acne?

    What types of spots do you get? (e.g, Whiteheads- small white pimples; Blackheads- small black pimples; Papules- small inflammed solid bumps; Pustules- small pus filled spots; Cysts- large fluid filled lumps) If you are unsure please upload some photos at the end.

    Does your acne cause scars?

    YesNo

    Do you suffer from any other skin conditions such as psoriasis, eczema, rosacea, etc.

    YesNo

    Please provide details on your other skin conditions?

    Are you currently using any medications to treat your acne?

    YesNo

    Please tells us what you are currently using?

    Have you experienced any side effects from this medication?

    YesNo

    Please tell us what side effects you have experienced?

    Are you currently pregnant or planning a pregnancy?

    YesNo

    Your answer to the above question has indicated this medicine is not suitable for you If you have any questions regarding this please feel free to contact us on support@digiderm.co.uk

    Do you suffer from irregular periods and/or excessive facial or body hair growth?

    YesNo

    Please note acne with irregular periods and/or abnormal hair growth can be a sign of a condition called polycystic ovary syndrome- More information can be found at- https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/
    If you are concerned you may have this condition we would recommend you discuss this with your GP.

    Do you understand and agree with the following?

    • You have read and understood the important medical information found in our Acne Guide in full.

    • You are aware that most acne treatments take 8-12 weeks to work and if there is no improvement after 3 months then you should contact a healthcare professional to review treatment.

    • You are aware you should not use more than one type of the same topical treatments at the same time- such as two different topical antibiotics or retinoids.

    • You are aware oral antibiotics cannot be used with topical antibiotics at the same time and that when using an oral antibiotic you should use topical Benzoyl peroxide, Differin or Epiduo at the same time to reduce the risk of antibiotic resistance. You are aware that all antibiotic treatments should not be used continuously for longer than 3-6months.

    • You are aware that if you have or develop severe scarring or psychological distress then you should see your GP as soon as possible.

    • You are aware that if you take the medications Isotretinoin (Roaccutane), Lithium or have been diagnosed with Kidney disease, Liver disease, SLE or Myasthenia Gravis then you should not take Lymecycline or other tetracycline antibiotics as this could cause you harm.

    • You agree with our terms and conditions and privacy policy. (Terms & Conditions | Privacy Policy)

    • You will read the patient information leaflet supplied with the medication we send you and if you are allergic to any of the ingredients you will not take the medication and contact the prescriber.

    • This treatment is to be used only by you.

    • The answers provided to the above questions are true and accurate.

    YesNo