Repeat Prescription Review

Disclaimer

Please be advised, this form is for existing RPM Derma customers wishing to reorder or modify their current prescription treatment. If you are a new customer wishing to receive initial treatment, please complete the following 'Medical Questionnaire' form:

Initial Medical Questionnaire

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

General Information

First Name *

Last Name *

DOB *

Treatment Review

Name of current treatment *

Duration of use of treatment (if known)

Any problems/concerns/irritations? *

YesNo

If yes, please provide further details: *

Any changes to general health? *

YesNo

If yes, please provide further details: *

Any changes to sexual health? *

YesNo

If yes, please provide further details: *

Any new medications/supplements? *

YesNo

If yes, please provide further details: *

Any problems with application? *

YesNo

If yes, please provide further details: *

Any changes to mood? *

YesNo

If yes, please provide further details: *

Any chance you could be pregnant? *

YesNo

*If there is a chance you could be pregnant, please contact the clinician at the earliest convenience*

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

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Treatment Continuation

Do you wish to continue with the same treatment or do you wish to request modifications? *

Continue with same treatmentRequest change/modifications

If you wish to request a change/modification to your treatment, please contact the clinician directly or book a consultation

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

Additional Information

Is there anything further you feel the clinician should know?

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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