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ACNE
First name
Surname
Date of Brith
Email address
Mobile number
Address Line 1
Address Line 2
Town / City
Postcode
Have you seen a Doctor face to face and been previously diagnosed with ACNE
How would you describe the spots that appear on your skin
Whiteheads / Blackhead
Inflamed spots on the surface of the skin
sore inflamed pustules below the surface of the skin
Are you aware that oral Lymecycline should not be taken whilst using Zineryt solution or Duac Gel?
Yes
No
Are you aware oral Lymecycline is best used with topical Differin, Epiduo or Peroxide gels, as this reduces the chance of bacteria developing
Yes
No
Please tick if you have any of these skin conditions ?
Eczema
Rosaea
Perioral Dermatitis
Cutaneous epithelioma
If yes to any of the above, please provide more details here.
Do you suffer from any problems with your kidneys?
Yes
No
Do you suffer from any problems with your urinary system?
Yes
No
Do you suffer from any problems with your digestive system?
Yes
No
Do you suffer from any problems with your Liver?
Yes
No
Are you taking any prescribed medication?
Yes
No
Your option here
If you are taking medicine, please list them here
Do you suffer from any other health condition?
Yes
No
Are you planning to become pregnant or breastfeeding?
Yes
No
Have you had any recent major operations?
Yes
No
Please list any medical conditions you have been diagnosed with
Do you suffer from Myasthenia gravis, lupus, G6PD, or Erthematosus?
Yes
No
Please confirm you understand the following
Please confirm you understand the following
Would you like us to notify your GP of this treatment?
Yes
No
If you would like us to notify your GP please enter the GP name and address below
Please upload a photo of the ACNE
I confirm
I am over 18 years of age
This medicine is for my sole use only
I will read the patient information leaflet regarding the side effects and dosages
I will take the responsibilty to inform my own GP regarding this consultation
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