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?
Are you pregnant, planning on becoming pregnant, or breastfeeding?
Are you allergic to any of the following?
Do you currently have sunburn?
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?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
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.
Do you agree to the following?