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Gender:
Date of birth
Have you been previously diagnosed with Rosacea by your doctor?
For how long have you been suffering from Rosacea?
For further information kindly contact our patient support team:
0207 867 3932
email help@clickpharmacy.co.uk.
When was the last time you were reviewed by a doctor about your Rosacea?
Which symptoms are you suffering from? Please tick all the symptoms that apply to you.
Do you suffer from any other symptoms?
Can you please provide more details?
Do you suffer from any of the following?
Are you taking any of the following?
Please provide the name, dosage and the reason why you are taking that medication or medications.
Are you taking any other medication not mentioned above (including over the counter medication, herbal medication or recreational drugs)?
Are you allergic to azelaic acid, brimonidine, ivermectine or to any of the ingredients in rosacea treatment?
Are you pregnant or breastfeeding or likely to become pregnant or start breastfeeding while taking this medication?
Do you have any other skin problems such as eczema, perioral dermatitis or cutaneous epithelioma?
Do you agree to the following?
Please tick the boxes to confirm the following:
Order before 15:00pm (Monday to Friday) for next day delivery
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