QuickScript Online Consultation Form - Acne
Welcome to QuickScript! Please complete this secure form to start your online consultation with an independent prescribing pharmacist.
Important Eligibility Criteria - Please Read Carefully
This service is suitable ONLY for experiencing typical UTI symptoms without red flag signs. If you fall outside this criteria or have 'red flag' symptoms (e.g., fever, back pain, nausea), please seek in-person medical attention from your GP or A&E as this service may not be suitable.
This service is for minor conditions. If you are experiencing a medical emergency, please call 999 or go to your nearest A&E.
The consultation fee is non-refundable if the pharmacist determines your condition is not suitable for online treatment and refers you to a GP or emergency services.
2. Medical History & Allergies:
Relevant Medical Conditions:
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Are you Pregnant/Breastfeeding?
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Are you Pregnant/Breastfeeding?
3. Acne -Specific Symptoms & History
What type of acne are you experiencing?
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What type of acne are you experiencing?
Where on your body is the acne located?(Select all that apply.)
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Where on your body is the acne located?(Select all that apply.)
How would you describe the severity of your acne?
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How would you describe the severity of your acne?
How long have you had acne?
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Have you tried any treatments before?
(Select all that apply)
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Have you tried any treatments before?(Select all that apply)
Did you notice any improvement with past treatments?
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Did you notice any improvement with past treatments?
Do you currently have any of the following symptoms or concerns?
(Select all that apply)
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Do you currently have any of the following symptoms or concerns?(Select all that apply)
Do you have any history of depression or other mental health conditions?
(Some acne medications can worsen mood in sensitive individuals)
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Do you have any history of depression or other mental health conditions?(Some acne medications can worsen mood in sensitive individuals)
Are you currently using any products with benzoyl peroxide, retinoids, or acids (e.g., salicylic acid, glycolic acid)?
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Are you currently using any products with benzoyl peroxide, retinoids, or acids (e.g., salicylic acid, glycolic acid)?
Have you used isotretinoin (Roaccutane) in the past?
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Have you used isotretinoin (Roaccutane) in the past?
I confirm that I have read, understood, and agree to QuickScript's [Privacy Policy] and [Terms of Service].
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I confirm that I have read, understood, and agree to QuickScript's [Privacy Policy] and [Terms of Service].
I understand that the consultation fee covers the assessment and potential prescription, but , which I will pay separately at the pharmacy.
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I understand that the consultation fee covers the assessment and potential prescription, but , which I will pay separately at the pharmacy.
I understand that the QuickScript pharmacist may determine my condition is not suitable for online treatment and may refer me to a GP or emergency services for an in-person assessment.
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I understand that the QuickScript pharmacist may determine my condition is not suitable for online treatment and may refer me to a GP or emergency services for an in-person assessment.
I confirm that all information provided in this form is accurate and truthful to the best of my knowledge.
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I confirm that all information provided in this form is accurate and truthful to the best of my knowledge.
