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

I understand if my ACNE gets worse or starts to scar I will see my GP

Please confirm you understand the following

I am aware it takes 8 weeks on continuous usage for ACNE treatments to work

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

ACNE

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