Eczema/ Psoriasis/ Skin Allergy Consultation Form

    Have you already been diagnosed with Eczema, Psoriasis or a Skin Allergy by a healthcare professional (e.g, GP, Consultant)?

    YesNo

    We would strongly recommend getting a formal diagnosis prior to ordering treatment- You can book an appointment with one of our clinicians by clicking here

    Do you plan on using this treatment for eczema, psoriasis or a skin allergy?

    EczemaPsoriasisSkin Allergy

    Please describe your current symptoms (eg, skin dryness, redness, itchiness, etc).

    Please state which areas of your body are currently affected by Eczema/Psoriasis (eg, face, hands, legs etc)?

    What areas of the body are you planning to apply this treatment? (e.g, face, hands, legs etc)

    Are you currently pregnant or planning a pregnancy?

    YesNo

    Note : We Cannot Prescribe This Medication

    APOLOGIES BUT WE ARE NOT ABLE TO OFFER THIS MEDICATION TO YOU. PLEASE SELECT AN ALTERNATIVE
    TREATMENT OR CONTACT US FOR FURTHER ADVICE ON SUPPORT@DIGIDERM.CO.UK

    Are you currently breastfeeding?

    YesNo

    Note : We Cannot Prescribe This Medication

    APOLOGIES BUT WE ARE NOT ABLE TO OFFER THIS MEDICATION TO YOU. PLEASE SELECT AN ALTERNATIVE
    TREATMENT OR CONTACT US FOR FURTHER ADVICE ON SUPPORT@DIGIDERM.CO.UK

    Are you currently using any medications to treat your Eczema/Psoriasis?

    YesNo

    Please list any medications you are currently using, including over the counter or prescription only and if they are effective. Please also include any information on medications you have tried in the past and whether or not they were effective.

    Do you agree with the following?

    • 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.

    • This treatment is to be used only by you.

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

    YesNo