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Date of birth
Have you been diagnosed with Acne by a medical doctor via a face to face consultation?
For further information kindly contact our patient support team:
0207 867 3932
When was the last time you were seen by a specialist regarding your acne?
0207 867 3932
Do you suffer from any of the following?
Can you please provide more details?
Are you taking any of the following medication?
Please specify which of the medicine(s) above you are taking and their dosage
Are you taking any other medication not mentioned in the question above?
Please provide the name, dosage and the reason why you are taking that medication or medications.
In order for us to prescribe you antibiotics, we are required to inform your regular GP. Do you give us consent to inform your GP about the supply of this medication?
Please enter your GP's full name and surgery address so we can contact them to advise of the medication you have ordered.
Are you allergic to lymecycline, oxytetracycline, doxycycline or to any of the other ingredients in these medicines such as lactose?
Are you pregnant or breastfeeding or planning to become pregnant or start breastfeeding during this course?
Do you currently suffer from sunburn, eczema grazes, cuts or broken skin (around the affected area)?
Do you understand that if your acne gets worse or starts to cause scarring, you must see your GP?
Do you understand that it usually takes 8 weeks of continuous usage for acne treatments to work and that your treatment should not exceed 12 weeks?
Are you aware of the following?
Do you agree to the following?
Please tick the boxes to confirm the following:
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