Consultation Form

    Do you plan on using this treatment for Eczema, Psoriasis, Allergy or Something Else?

    EczemaPsoriasisAllergySomething Else

    Have you previously been diagnosed with Eczema, Psoriasis or an Allergy by an appropriate healthcare professional (e.g, GP, Consultant, Pharmacist, Nurse)?

    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 describe your current symptoms (e.g., skin dryness, redness, itchiness etc).

    Please state which areas of your body are currently affected (e.g., face, hands, legs etc)?

    If you are using a cream, gel or solution- what areas of the body are you planning to apply this medication (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 [email protected]

    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 [email protected]

    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.


    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 if you develop any new, worsening or treatment-resistant rashes you should see your GP. You are aware if you have any signs of a severe allergic reaction such as difficulty breathing, dizziness, wheezing, swelling of lips, tongue or throat then you should contact emergency care services immediately. You are aware that if you have any signs of infection, or if you feel generally unwell (e.g. you have a fever, temperature, nausea or vomiting) then you should contact urgent care such as your GP or NHS out-of-hours.

    • You are aware that paraffin containing products can cause a fire hazard.

    • You are aware that steroid creams should be applied thinly and for short term use because they can otherwise cause skin damage, and that when treating eczema and psoriasis you should always use regular emollients alongside steroids as the main form of long-term treatment.

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

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