Your Details

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Patient Name

Please enter the patients full name

Date of Birth *

Gender *

Is there any possibility you are or may become pregnant in the next 6 weeks?

Your Condition

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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Pharmacy Nomination

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 Name

Pharmacy Address?

Pharmacy telephone or email

GP Details

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 name *

GP address *

GP telephone or email

Medical Questions

Please select which is most relevant

Are you diabetic?

Diabetic Details

Do you have any allergies?

Allergie Details

Are you taking any prescription medication?

Prescription Details

Are you taking any non prescription medication, herbal medicines or illegal drugs?

Medication Deails

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)?

or other?

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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