Eczema/Psoriasis/ Skin Allergy Consultation Form

    Have you been diagnosed with Eczema/Psoriasis by an appropriate clinician (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 or psoriasis

    EczemaPsoriasis

    Please list 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 cream (eg, face, hands, legs, etc)?

    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

      Rosacea/ Perioral Dermatitis Consultation Form

      Have you previously been diagnosed with rosacea/ perioral dermatitis by a healthcare professional (e.g. GP, consultant)?

      YesNo

      We recommend getting a diagnosis from a healthcare professional before ordering treatment. You can discuss this with your GP or book for a consultation with one of our specialists clicking here

      How long have you suffered with rosacea/ perioral dermatitis?

      What areas of your body are affected by rosacea/ perioral dermatitis?

      Please describe your symptoms including how your skin looks and feels?

      Does anything make your skin worse or better?

      Please list any treatments or medications you have tried previously and tell us about about your experience using these treatments? e.g. were they effective? did you get any side effects?

      Have you recently used steroid creams or ointments on your face? Examples of these include: hydrocortisone, Betnovate (betamethasone), Eumovate (clobetasone), etc)

      YesNo

      Please tell us what you used and for how long?

      Do you suffer from any other skin conditions?

      YesNo

      Please tell us about your other skin conditions and any treatment you use for these?


      Now Please take 3 photos of your skin and attach them below:


      If taking pictures of your face make sure you take off your glasses, keep your hair out of your face and remove any make up if you are wearing any.


      Find a good light. You can do this by standing in front of a window.


      Turn off any filters on your device so we can see the real you.


      Make sure your skin problem fills the screen so we can zoom in as needed. Don’t hold your device too far away from your skin as it will be harder to see.


      All pictures uploaded are 100% confidential and will only be looked at by the clinician involved.


      Click on the camera icon below to upload photos. Please take three photos and try to vary the angles take one looking straight at the skin issue and the other two viewing it from either side.


      Choose Your Front Facing Photos. (We accept JPEG, JPG, PNG, Max 5MB Per Photo)


      Choose Your Left Facing Photos. (We accept JPEG, JPG, PNG, Max 5MB Per Photo)


      Choose Your Right Facing Photos. (We accept JPEG, JPG, PNG, Max 5MB Per Photo)

      Do you understand and agree with the following?

      • You are aware that topical treatments for rosacea/ perioral dermatitis should not be applied close to the eyes, lips or to open sores.

      • You are aware not to take Metronidazole (e.g. Rozex) or Tetracyclines (e.g. Efracea) if you are taking Warfarin or other types of coumarin blood thinning tablets.

      • You are aware Mirvaso can cause worsening of symptoms in about 1 in 5 people and you should stop using the product and consult your GP if your symptoms worsen. You are aware you should not use Mirvaso if you have low blood pressure.

      • You are aware that you cannot use Soolantra, Mirvaso or Tetracyclines (e.g. Efracea) if you have depression, liver or kidney disease, Sjogren syndrome or poor circulation. You are aware you cannot use Efracea if you have Myasthenia Gravis, Colitis, Gastrointestinal disease or if you use medications to reduce stomach acid e.g. omeprazole.

      • You are aware Soolantra may worsen symptoms in the first few days but this should settle. If it doesn't then please stop using the medication.

      • You are aware that if you are using Tetracycline antibiotics (e.g. Efracea) you should avoid sources of strong UV light.

      • You agree with our terms and conditions and privacy policy, you are at least 16 years old and currently resident in the UK. (Terms & Conditions | Privacy Policy)

      • You will read the patient information leaflet supplied with the medication we send you and if you suspect it contains any ingredients you are allergic to 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

        Psoriasis Consultation Form

        Have you been diagnosed with psoriasis by a GP or dermatologist?

        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

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

        Please state which areas of your body are affected by psoriasis?

        Are you currently using any medications to treat your 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

          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

            Acne Pill Quiz

            Are you currently up to date with your smear tests?

            YesNo

            Please tell us why you are not up to date with your smears?

            Have you ever been told by a medical professional that you should not use hormonal contraception?

            YesNo

            Please tell us more about this?

            Do you currently use hormonal contraception (pill/patch/implant/coil/injection)?

            YesNo

            Please tell us what contraceptive you currently take?

            Please tell us how long you have been using this contraceptive?

            Are you currently in a sexual relationship and interested in using this medication for its contraceptive effect?

            YesNo

            Do you have any concerns about your sexual relationship that you feel you would like to discuss with a healthcare professional in private?

            YesNo

            Do you wish to try a long acting contraceptive such as an implant, injection or coil?

            YesNo

            If yes stop patient from continuing and say- We do not offer long acting contraceptive options at digderm and focus on contraceptives with proven benefit in acne. If you wish to try a long acting form of contraception we recommend contacting your GP or local sexual health clinic.

            Do you suffer with migraines?

            YesNo

            Do you have aura with your migraines?

            • Aura includes the following symptoms:

            • Visual disturbances: Spots of blindness in your eyesight, sparkles or stars in the field of vision, zig zag lines, temporary blindness, tunnel vision, coloured spots.

            • Other aura symptoms can include: Numbness and tingling, pins and needles, vertigo (sensation of the room spinning), weakness on one side of the body.

            YesNo

            Please tell us more about your symptoms during a migraine aura?

            Do you smoke?

            YesNo

            What is your height and weight?

            Height
            feetcm

            feet :Inches :

            cm :

            Weight
            stonekg

            stone :lbs :

            kg :

            Please provide us with an up to date blood pressure. This should be from within the last 3 months.

            Systolic (Higher number)-

            Diastolic (Lower number)-

            Have you or anyone else in your family ever been diagnosed with any of the following:

            • Varicose veins;

            • Epilepsy;

            • High blood pressure;

            • Hyperlipidaemia (raised fat levels in the blood);

            • Epilepsy;

            • Any bleeding disorder or blood clot;

            • Breast, ovarian, cervical or uterine cancer;

            • Vaginal bleeding of unknown cause;

            • Endometriosis;

            • Varicose veins;

            • Disease of the gall bladder or liver.

            • Lupus or porphyria.

            YesNo

            Please provide us with more information about this?

            Do you take any of the following medicines:

            • St Johns Wort;

            • Bosentan;

            • Rifampicin or rifabutin (antibiotics for TB);

            • Carbamazepine, oxcarbazepine, phenytoin, phenobarbital, primidone, topiramate (for epilepsy);

            • Nelfinavir, nevirapine or ritonaivir (for HIV);

            • Tetracycline or ampicillin antibiotics;

            • Boceprevir or telaprevir (For hepatitis C);

            • Etoricoxib (For pain and inflammation);

            • Modafanil (for narcolepsy);

            • Metoclopramide (for sickness);

            • Griseofulvin (For fungal infections).

            YesNo

            These medicines interact with this pill and reduce its contraceptive effect. It is fine to
            still use it for acne alone but this can not be relied upon for contraception and you should speak to
            your doctor about alternative contraceptive options.

            Please confirm that you understand this and will not use this pill as a contraceptive

            YesNo

            we are not able to provide this medication as
            a contraceptive due to an interaction with one of the medicines you are currently taking. If you have
            any further questions please contact us on support@digiderm.co.uk

            Have you had any of the following?

            • A heart attack or stroke;

            • A serious mental health condition that lead to an admission to a hospital or specialist centre;

            • Major surgery;

            • Reduced kidney or liver function;

            • A serious side effect or allergy to hormonal contraception.

            YesNo

            Please provide more details about this?

            Do you understand that:

            • No contraceptive is 100% effective at preventing pregnancy

            • With these medications there is a very low risk of some serious side effects such as: cervical cancer, breast cancer and blood clots.

            • This medication will not provide protection against sexually transmitted infections (STIs)

            • You should take your pill at the same time each day.

            • If you miss a pill please review the Patient Information Leaflet for advice on what to do and if you are still protected from pregnancy.

            • Your pill may not work as well if you vomit or have severe diarrhoea. If this occurs, continue to take the pill as normal but use condoms whilst unwell and continue for 7 days from when you have fully recovered.

            • You should take the pill as directed by the information pack provided or by your clinician.

            • Long acting contraceptives such as the injection, implant and coil are generally considered more effective in preventing pregnancy. These options do not have any known benefit in acne. If you are taking this medication for contraceptive effect, you should consider discussing long acting contraception options with your GP or sexual health clinic.

            YesNo

            It is important that you understand the above
            statements and we can not provide you with this medication unless you do. If you have any
            questions about these statements please email support@digiderm.co.uk

            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

              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

              Yes- Please tell us what side effects you have experienced?

              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 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

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                Express Consultation Service - £35

                IMPORTANT INFORMATION: - Please read the FAQ section before you start- this will tell you more about this service, including the types of skin problems we can and cannot treat. Once you have submitted this consultation form, one of our dermatology clinicians will get back to you via Email or WhatsApp within 24-48 hours, with some advice and suggestions for treatments.

                Please note: We do not advise on suspected skin cancers, moles, growths, lumps, or wounds. This consultation does not include the cost of any prescription medications or treatments, but if needed these will be made available for you to purchase via your DigiDerm account.

                Please tell us which part(s) of the body are affected?

                How long have you had your current skin problem?

                Does it come and go or is it always there?

                Does anything make it better or worse?

                How does your skin feel and look? e.g. is it sore, red, itchy, greasy, dry, flaky, cracked, hard, bleeding, weeping, crusty, pus-filled or warm? Please give as much detail as possible.

                Do you have any other symptoms or concerns?

                0%

                Do you have any allergies including to any medications?

                YesNo

                Please list all of your allergies including to any prescribed medications:

                Do you have any current or previous medical conditions?

                YesNo

                Please list your current and past medical conditions:

                Have you already received a formal diagnosis from a healthcare professional e.g. doctor/ pharmacist/ nurse?

                YesNo

                Please tells us what this diagnosis was?

                If you have received a diagnosis do you think it is correct?

                YesNo

                Please tell us why you think it is incorrect and what else you think it might be?

                Have you tried any current treatments and/or do you take any other prescribed medications?

                YesNo

                Please tell us what treatments you have tried & if any have helped. Next to each treatment put a number from 1 to 10 (1 = didn't help at all, 10= it was very effective). Please also list any other prescription or over-the-counter medications you are taking for other conditions.

                *For Females

                Are you currently pregnant, planning a pregnancy or breast feeding?

                PregnantNot pregnant but planning a pregnancyBreastfeedingNone of the above.

                Are there any other comments you’d like to make or is there anything else you think we should know that would prevent us from safely and appropriately recommending medications and products?

                YesNo

                50%

                First Name:

                Last Name:

                Date of Birth :

                Telephone Number:

                Email Address

                What is your gender?

                MaleFemaleOther

                How did you hear about our express consultation service?

                GoogleInstagramTikTokYouTubeWord of mouthLeaflet/ PosterOther

                Please take 3 photos of your skin

                Try to take at least 1 photo that is a close up of your skin (zoomed in) and one photo that is a bit further away. If you have multiple body parts that are affected then you can send 1 photo of each part. If you want to send us more photos then you can send them to us via email (support@digiderm.co.uk)- please include your name and date of birth in the subject of the message.

                Click on the camera icon below to upload photos.

                Choose Your Front Facing Photos. (We accept JPEG, JPG, PNG, Max 5MB Per Photo)

                Choose Your Left Facing Photos. (We accept JPEG, JPG, PNG, Max 5MB Per Photo)

                Choose Your Right Facing Photos. (We accept JPEG, JPG, PNG, Max 5MB Per Photo)

                We Request 3 Photos in Total:

                • 1 x front Facing

                • 1 x From Left Facing

                • 1 x From Right Facing

                Would you like to receive occasional DigiDerm promotional material like discounts, useful skin tips and new treatments?

                YesNo

                [stripe* stripe-85 "Make Payment"]

                100%