Medical Questionnaire

Disclaimer

Please be advised, in order for the Dermatology Specialist to provide feedback, you will be required to submit a minimum of TWO clear photographs of the affected area for review.

General Information

Patient first name *

Patient surname *

Date of birth *

Email Address *

Mobile / Phone number *

Gender at Birth *

MaleFemale

We request for patients to confirm their gender assigned at birth as sex hormones can significantly influence treatment outcomes.

Photo ID *

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We require photographic identification to verify that the prescription is issued exclusively to the intended individual. This is in accordance with CQC regulatory requirements and ensures that all patient safety protocols are fully upheld.

Address *

Street address *Street address line 2

City *

Postcode *

Occupation

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Health Information

Do you have any medical conditions, you are treated or known for ? i.e, asthma, eczema, hypertension , other *

YesNo

Please list all your medical conditions

Check the one which applies to you *

Pregnant Breastfeeding Planning to become pregnant in near future Not pregnant or breastfeeding

Any means of contraception? Please list i.e pill, coil, implant

Please list any condition which are significant and not mentioned

Are you taking any prescribed medications? *

YesNo

Please list your current prescribed medications, including dose

Are you taking any supplements, herbal treatment, alternative treatment? *

YesNo

Please any supplements, herbal treatment, alternative treatment you are currently taking

Do you have any medication allergies? *

YesNo

Please list any medication allergies

Do you have any other allergies and known intolerances ? i.e . pollen, plaster, food *

YesNo

Please list all your other allergies and known intolerances

Your Concern

WHAT IS YOUR CONCERN TODAY ? *

Hair and Beard Area ( hair loss, reduced density etc.)Skin Condition ( acne, rosacea, melasma, pigmentation etc)

Please provide more information

Provide more information

Please describe

Please provide more info

When did you first noticed your symptoms?

Has anyone in your family had the same symptoms or currently having?

History of treatment up to today. Please list all prescribed and over the counter treatment

Please upload clear and sharp photos of concerned areas. 2 minimum *

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Treatment

Please specify the name of the treatment you wish to purchase *

If you require an active discussion with the Dermatology Specialist, please book via the links below

Please be advised, WhatsApp / Phone Call and Video Call consultations are a remote discussion.

Should you wish to book your remote discussion for Monday, Tuesday or Friday, please selected our Market Harborough location.

Should you wish to book your remote discussion for Wednesday, Thursday or Sunday, please select our Leicester location.

WhatsApp or Phone Call | £30 (redeemable against purchased product)

Video Call | £149

In Person Consultation | £160

Our admin team may request additional information via email or phone. However, should an active discussion with a clinician is required via WhatsApp or phone call (approx. 5 mins), this will be charged at £30, redeemable against purchased product. Please be advised, in some cases, a higher-tier consultation may be required to ensure safe and effective treatment.

Consent

By submitting this form, you are declaring that all the information provided is true and complete to the best of your knowledge. You confirm that you have not omitted any details that could affect your ability to receive treatment or safely use the product. You understand that providing inaccurate or incomplete information may impact the safety and effectiveness of your treatment. *

Your personal and medical information is collected and stored securely in accordance with the UK General Data Protection Regulation (GDPR) 2018 and the Data Protection Act 2018.This information is used solely for the purposes of providing safe and effective medical care, managing your treatment, and fulfilling legal or regulatory obligations.

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