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Date of Birth
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Is there any possibility you are or may become pregnant in the next 6 weeks?
Tell us about your condition
How long have you had the condition?
Your skin colour?
Your hair colour?
Your eye colour?
Picture of effected area
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If our doctor recommends medication, we will send a private prescription to your nominated pharmacy for you to purchase the medication, you can of course choose to discuss the doctors report with your own GP and request an nhs prescription in the usual manner.
Pharmacy telephone or email
We need to inform your GP for their records if medication is prescribed.
Do you give give your consent to us informing your GP?
GP telephone or email
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Are you diabetic?
Do you have any allergies?
Are you taking any prescription medication?
Are you taking any non prescription medication, herbal medicines or illegal drugs?
Are you being treated for any other medical condition?
Other Medical Condition Details
The Skin Condition
Please tell us more about your skin condition
Is it a Rash?
a Lesion (lump/mole)?
History of condition or other relevant info
Please give the full history of the condition and any other relevant information or question for the doctor.
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