Raf

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symtoms

Have you previously been diagnosed with mild to moderate eczema by a medical doctor?

Yes No

How long have you suffered with eczema?

Select the most appropriate answer:
This is the first time
Less than one year
Two to five years
Five or more years

Which parts of your body require treatment with this eczema product?

Please describe the area that needs treatment including its location on the body and appearance.

Health

Do you have an allergy?

Yes No

Do you suffer with any other skin conditions?

Yes No

Are you pregnant, planning on becoming pregnant, or breastfeeding?

Yes No

Do you regularly moisturise your skin (especially areas that are prone to be dry and/or cracked)?

Yes No

Are you aware you should see a doctor about new rashes, worsening rashes, and rashes not responding to treatment?

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Are you aware that you can’t use the cream on the face or on the front of the neck?

Yes No

Are you aware that:

You should see your doctor if your condition does not improve within 7 days.
You should not use a steroid (such as betamethasone) on large areas of the body for more than two weeks without advice from your doctor.
Betamethasone (Betnovate) should not be applied under a bandage or to broken skin.
Betamethasone (Betnovate) should not be applied near the eyes or eyelids.

Yes No

Agreement

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Medical Assesment Eczema