Before we continue, do you agree and consent to the following? All answers are provided by me and will be completely truthful. I will be the sole user of any medication offered to me through this service. I am aware that some medications prescribed to me will be unlicensed medication. I am over 18 years of age and a resident of the UK. Yes, I agreeSelect *Please confirm your sex assigned at birthMaleFemaleWhy are you seeking treatment from us today? Please select all that apply *Skin textureFine linesAcne scarringHyperpigmentationMelasma/ chloasmaPlease tell me the area of your body you are seeking treatment for *FaceAnywhere else on bodyPlease tell me which parts of your body you intend to treatHow would you describe your skin type? *Greasy or oilyNormal or mixedDry or sensitiveAre you currently using any over the counter or prescribed treatments for your skin? *YesNoPlease tell me the names of the treatment(s) you are using and what these are forIs the treatment helping? *YesNoSomewhatI want to tell you in more detailPlease tell me more about thisDo you have any problems or troublesome side effects with this medication? *YesNoPlease tell me more about thisHave you been prescribed any topical treatments for your skin in the past? *YesNoPlease tell me the names of the treatment(s) you have used and what these were forIs the treatment helping? *YesNoSomewhatI want to tell you in more detailPlease tell me more about thisDid you have any problems or troublesome side effects with this medication? *YesNoPlease tell me more about thisDo you have a history of asthma? *YesNoDo you have any other significant medical conditions or illnesses? *YesNoPlease tell me more about thisAre you pregnant or planning a pregnancy soon? *I’m not pregnant or planning a pregnancy soonI am currently pregnant - please recommend a suitable treatment for meI am planning a pregnancy soon - please recommend a suitable treatment for meAre you using contraception? *I’m using effective contraceptionI’m not at risk of pregnancyI’m sexually active but not using contraception. Please recommend a suitable treatment for me.I’m not sure my method of contraception is suitable for all treatment optionsI am already pregnant, or planning a pregnancy soon. Please recommend a suitable treatment for meAre you currently breastfeeding? *Tretinoin can be used while breastfeeding - but should not be applied to the chest/ breast, to avoid contact with the baby.No, I am not breastfeedingYes, I am breastfeeding.Do you take any prescription medication? *Steroids or others medications for your scalpNoOtherPlease tell me moreDo you take any over the counter medications? *Including any vitamins, supplements etc.YesNoPlease tell me moreDo you have an allergy to any of the following? *TretinoinOtherNo known allergiesPlease tell me moreUpload a photo (optional)This will help our prescriber determine whether this is the right treatment for you, or not.Drag and Drop (or) Choose FilesYour legal first name *Your legal last name *Date of birth *Email Address *Phone *Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal Code *CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweCredit / Debit Card *Submit
