Acne consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Who diagnosed your acne? *

My GP
Myself
A dermatologist
Other

Please can you tell us who first diagnosed your acne? *

Please can you tell us where the acne is located? Select one or more answers *

Face and neck
Shoulders
Back
Chest
Bottom
Other

Please can you provide more details about where the acne appears *

Please can you tell us what type of acne you have? Select one or more answers *

Whiteheads, spots or pustules
Blackheads
Cysts or Nodules
Redness
Other

Could you please provide more details about your condition *

Other than the spots and blemishes on your skin does the acne cause you any other physical symptoms in your body? *

Please can you provide more details about the physical symptoms you are experiencing with your acne? *

When did your acne start? Select one answer *

It has just started
1 – 5 years ago
5 – 10 years ago
More than 10 years ago

Are you currently using acne treatment? *

Please can you tell us more about what you are currently using?

What is the name of the treatment(s) you are currently using?
Are you intending to use this/these treatment(s) alongside or instead of the treatment you have ordered?
If you are using them together who has advised you to use these treatments together?

Are you currently using any acne treatment *

Do you currently have any of these skin problems? Select one or more answers *

Eczema
Rosacea
Perioral dermatitis
Skin cancer or actinic keratoses
None of these

We’re sorry, but there are no suitable treatments for you.

The safety and well-being of our patients is our number one priority, and based on your answers, we can’t recommend any of our treatment options. We know this is both frustrating and disappointing, but we want to make sure that we’re putting your health first and that you find the right care.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Please can you tell us more

Is the acne located in the same area as your other skin condition?
Have you used acne treatment since your diagnosis?
What treatments are you taking for this condition?

Other skin conditions *

Please upload a picture of your acne. If this is on the face, please include a picture showing the full face.

Please upload a photo of your acne

Click or drag a file to this area to upload.

Please select your treament *

Tetralysal or Lymecycline capsules
Clindamycin based treatments like Dalacin, Duac, Clindamycin
Benzoyl peroxide containing products like Acnecide
Adapalene containing products like Differin, Edpidua
Skinoren cream
Treclin cream

Have you used Acnecide before? *

Did you experience any side effects when using Acnecide? *

Please tell us what the side effects you experienced when using Acnecide? *

Do you understand that:

You should avoid excessive exposure to sunlight or UV lamps whilst using Acnecide.
Acnecide may bleach hair and coloured fabrics including clothing, towels and bed linen. Be careful to avoid contact of the gel with these materials.
Acnecide should not be applied to damaged skin.

Acnecie understanding *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do any of the following apply:

You are allergic or hypersensitive to Acnecide (benzoyl peroxide) or any of the ingredients.
You have used Acnecide before and suffered serious side effects.
You are using Acnecide for reasons other than to treat acne.

Acnecide allergy *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you used Treclin cream before? *

Did you experience any side effects when using Treclin cream? *

What side effects did you experience when you used the Treclin cream? *

Have you used Adapalene containing products like Differin or Epiduo before? *

Did you experience any side effects when using Adapalene containing treatments? *

Please tell us more about the side effects you experienced when you used the Adapalene containing treatments? *

Topical retinoids like Differin and tretinoin can be harmful to an unborn baby. Do you understand that women of childbearing age that are sexually active need to take adequate contraceptive measures to prevent pregnancy whilst using Differin?

Please Confirm *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you used Clindamycin based treatments before? *

Did you experience any side effects when you used the clindamycin based treatments? *

What side effects did you experience with the Clindamycin based treatments? *

Have you used Skinoren before? *

Did you experience any side effects when taking Skinoren? *

Please can you tell use what the adverse effects you experienced when taking the Skinoren cream *

Do you currently use any of the following medications?

Any oral antibiotics
Dapsone
Corticosteroids (e.g hydrocortisone, prednisolone)
Muscle relaxants
Warfarin or other anticoagulants

Acne medicines CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you suffer from chronic inflammatory bowel disease (e.g. Crohn’s disease or ulcerative colitis) *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you aware that:

You should avoid strong sunlight or UV light while using topical acne treatments
Ideally, only one topical acne treatment should be used at a time or if you need multiple treatments they should be applied at different times
Topical treatments should not be applied to skin that also has eczema or broken skin
If you experience irritation you should stop using it temporarily then try using on alternate days

Skinoren confirmation *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you tried tetralysal or lymecycline before? *

Did you experience any side effects when using Tetralysal or Lymecycline? *

Please can you tell us what the adverse effects to Tetralysal or Lymecycline were *

Do you take any of the following medications:

Any oral antibiotics
Retinoids or vitamin A (such as isotretinoin to treat acne)
Anticoagulants (such as warfarin)
Diuretics (water tablets such as furosemide)
Diabetes treatments (such as insulin and glibenclamide)
Ergotamine or methysergide

Tetralysal or lymecycline CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any of the following

Myasthenia gravis.
Porphyria.
Systemic lupus erythematosus (SLE)

Acne condition Red Flags *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you aware that Tetracyclines (minocycline, doxycycline, lymecycline and oxytetracycline) can be harmful to an unborn baby. Do you understand that women of childbearing age that are sexually active need to take adequate contraceptive measures to prevent pregnancy whilst taking oral tetracyclines?

Tetracycline warning *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you understand:

You should use a topical treatment alongside oral treatments for the best results
This medication should be taken on an empty stomach, this is usually one hour before food or two hours after food
You need to have a two-week break from this medication every six months to ensure that you still need it
Topical treatments remain the first-line treatment for acne

Do you understand about Tetralysal or Lymecycline *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

What is your biological sex? *

Male
Female

Are you pregnant, breastfeeding, or trying for a baby? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any other medical conditions not already mentioned? *

Please provide more details *

Are you taking any other medications that have not already mentioned? *

Please share details of any other medical conditions you have and any medications you are currently taking. Be sure to include the name of each medication, the dosage, and how long you’ve been using it

Other medication *

Do you have any other allergies that you have not previously mentioned? *

Please give us more details on these allergies *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about your own healthcare
I shall be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me and are truthful.
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
If prescribed a treatment, I will read the Patient Information Leaflet (PIL) that will be provided.
If prescribed a treatment, I will inform my GP of my treatment and contact them if I have any side effects associated with the treatment.
You agree to our terms and conditions, privacy policy and acceptable use policy
You are aware you will be subject to a soft check to validate your identity using LexisNexis.

Checkboxes *

I agree to the statements and give my consent for any treatment provided.

Are you registered with a GP in the UK? *

(Optional) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Summary care records

I consent

(Optional) Do you give us consent to write to your GP to share information of this supply and any information we hold about you?

Send information to GP

I consent

Product Category

Important

We review all orders to ensure they’re the best treatment we can offer you. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide what you ordered is unsafe for you, given the other information you provided, we won’t issue any treatment. However, we may call you and suggest alternatives.

Acne consultation

Topical retinoids like Differin and tretinoin can be harmful to an unborn baby. Do you understand that women of childbearing age that are sexually active need to take adequate contraceptive measures to prevent pregnancy whilst using Differin?

Do you agree and consent to the following?

Conditions

Treatments

Care and policies