Acne - Medcare-healthclinic & Pharmacy

Are you Male or Female?*

Male

Female

Are you currently suffering from mild to moderate acne which has now or previously been diagnosed by a medical professional?*

Yes

No

Has this medication been previously prescribed to you by your GP?*

Yes

No

How long ago did your acne start?*

In the last year

1-5 years ago

More than 5 years ago

Where is your acne?*

Face

Neck

Shoulders or back

Chest

Other

Is your acne restricted to the face in the following areas, chin, cheeks or T-zone?*

Acne presenting in other areas may require further investigation and needs to be treated by your own GP

Yes

No

Please upload a picture of your acne, ensuring you capture all of the area affected, for the face please include the whole face.*

This is compulsory, a picture will help our healthcare team to make an appropriate decision about your treatment.

Max. file size: 100 MB.

Does your acne include any hard lumps or cysts?*

Lumps under the skin (nodules) or cysts (very large, pus-filled lumps that are similar to boils), need to be seen by your doctor as this may result in scarring and will need monitoring regularly.

Yes

No

How would you describe your skin type?*

Greasy or oily

Normal or mixed

Dry or sensitive

Some acne treatments can cause dryness and redness when you start using them. This usually improves over time. I'd suggest you use an oil free moisturiser to help*

I understand

Are you currently using any prescribed treatment for your acne?*

Yes

No

If yes please provide the names*

Antibiotics are not a first line treatment for acne and should only be used when other treatment options have failed and been exhausted.*

Therefore if nothing is listed your request may be rejected

I understand

Are you aged OVER 31?*

Acne continuing beyond or after this age may require further investigation.

Yes

No

Have you tried any other acne treatment(s)?*

(If this is your first, please enter 'n/a')? Antibiotics are not a first line treatment for acne and should only be used when other treatment options have failed and been exhausted. Therefore if nothing is listed your request may be rejected

Are you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?*

Yes

No

Please tell us the NAMES of all the medicines you take e.g. tablets, inhalers, creams, patches & other injections. We need to check for interactions and prescribe safely

Do you have any of the following conditions?*

1. History of inflammatory bowel disease or antibiotic-associated colitis 2. You or any of your close family have had skin cancer 3. Problems tolerating this or similar medicines in the past (you have found them too irritating for your skin) 4. Eczema 5. Redness of the skin, broken blood vessels and tiny pimples usually in the centre of the face (rosacea) 6. Redness and soreness around your mouth (perioral dermatitis) 7. Skin reactions in the sunlight sun burn 8. Kidney disease 9. Liver disease 10. Systemic lupus erythematosus (SLE) 11. Myasthenia gravis 12. Acute porphyria 13. Suffer from thrush whilst being treated with antibiotics 14. Suffering from syphilis.

Yes

No

Do you have, or have you had, any of the following conditions?*

Please tick ALL that apply

Crohn's disease or ulcerative colitis

Antibiotic induced colitis

Rosacea

Perioral dermatitis

Facial eczema

None of the above

If yes, please tell us more*

Are you allergic to any of the following?*

1. Adapalene, Benzoyl peroxide, Clindamycin, Lincomycin 2. Erythromycin, 3. Isotretinoin, Tretinoin 4. Lymecycline, Oxyteracycline, Doxycycline or Minocycline 5. Propylene Glycol, Zinc

Yes

No

If yes please tell us more*

Do you have any known allergies to anything?*

Yes

No

If yes please tell us more*

Will you be pregnant or breast feeding at any point whilst taking this medication or within the next six months?*

This treatment is not suitable for use in pregnancy. Treatment should be discontinued for at least one cycle prior to pregnancy. Usage during pregnancy can cause birth defects and effective contraception must be used. It is essential that you do not become pregnant while using this treatment. Stop using your treatment immediately if you forget to use your contraception. If you think there is a possibility of pregnancy, discontinue treatment and speak to your GP immediately.

Yes

No

Important*

Certain acne medications, including those containing retinoids or adapalene (such as Differin, Aknemycin Plus, or Epiduo), pose a risk of causing abnormalities in an unborn foetus if used by pregnant women. Therefore, if you are of childbearing age and sexually active with men, it's crucial to use reliable contraception, such as a combined hormonal contraceptive pill along with condoms, or have a contraceptive implant or coil. We strongly advise discussing with your doctor prior to starting any acne medication to ensure there is no risk of pregnancy.

I understand

Do you understand that some acne medication can make your skin more sensitive to sunlight (photosensitivity) and you need to?*

1. Protect your skin from the sun, by using a sunscreen product and wearing clothes to stop you getting sunburnt. 2. Avoid using sun beds (sun lamps) or spending a long time in the sun. 3. Very cold or windy weather may also irritate your skin.

I understand

Do you understand the following*

That it can take 4-12 weeks of treatment before beneficial effects are seen, and treatment should not exceed 12weeks? that most people will experience some skin redness and peeling during the first few weeks of treatment? If irritation persists or symptoms are severe, or scarring occurs then stop using the medication and seek medical advice

I understand

Is there anything else you think we should know?*

Please enter extra information here if needed

Would you like us to tell your GP about any care we provide? Ideally your GP should know about any medicines you’re taking. Yes No (This won't affect our review of your order, but we would encourage you to tell your GP)*

Yes

No

Please provide your GP details*

Full name, address and post code of your GP surgery

You agree to:

●1) Read the patient information leaflet included with your medication or accessed via the provided link. ●2) Use the treatment exclusively for yourself. ●3) Confirm the accuracy of all information you've provided, understanding that our prescribers rely on this information to make decisions, and incorrect information could harm your health. ●4) Understand that we may need to contact you by phone or video call to ensure the medicine is suitable. Your order may be delayed if we can't reach you when necessary. ●5) Consent to treatment from MedCare Health Clinic, affirming your mental capacity to make this decision. ●6) The treatment decision is a joint consideration between you and the prescriber, but the final decision and approval rest with the prescriber. ●7) If treatment is deemed unsuitable, you will be directed to alternative care. ●8) Seek medical advice if you experience side effects, start new medications, or if your medical conditions change during treatment. ●9) Inform your GP about this prescription, as it is best practice to notify them of any private treatment. ●10) All treatment remains confidential. ● I confirm that I am over 18 and I agree to the Terms and Conditions

Yes I agree

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