Are you registered with a GP practice in the UK?

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.)

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

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

How long have you suffered from acne?

What treatment are you currently taking for your acne?

What area of your body is affected?

Do you have, or have had any of the following? Regional enteritis (crohn’s disease), Ulcerative colitis (inflamed colon or rectum), Inflammatory bowel disease or antibiotic-associated colitis (including pseudomembranous colitis)

Have you recently undergone procedures such as, chemical hair treatments, chemical peels and laser resurfacing of the skin?

Do you have an allergy?

Do you suffer with any other skin conditions?

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

Do you understand that usage during pregnancy can cause birth defects and you must use effective contraception if there is a possibility you may become pregnant?

Do you currently have sunburn?

Does your skin scar when healing?

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

Do you understand that it can take 4-8 weeks of treatment before beneficial effects are seen?

Do you understand if your acne gets worse or starts to cause scarring, you must see your GP?

Do you understand that this medication can make your skin more sensitive to sunlight (photosensitivity)? You should avoid sunlight and sunlamps while using this gel and take care to use sunscreen and cover in protective clothing if sunlight exposure is necessary.

Do you understand that treatment should not exceed 12 weeks?

Do you understand that you should use your treatment once a day, after washing your face with a mild cleanser and fully drying?

Do you understand that this medicine must not come in contact with eyes, mouth, mucus membranes, or eczematous/ broken/ sunburned skin, and that if it does by accident you should seek medical advice?

Do you understand that most people will experience some skin redness and peeling during the first few weeks of treatment? If your skin becomes irritated, you may need to use an oil-free moisturiser, use your treatment less often, or stop using it for a short period to allow your skin to recover and then re-start treatment. If irritation persists or symptoms are severe, stop using the medication and contact our help desk or your GP.

• 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.