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Customer Order Form

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Name *

First

Last

Email

Phone

Items(s) ordered

Deposit paid

approximately 50% deposit required

Ordered by (staff name)

enter staff name that placed the order

Staff use only

Item(s) ordered

Yes
No

Supplier

Complete below when item(s) are delivered to store

Layout

Customer contacted to collect order

First Contact

Customer contacted to collect order

Second Contact

Customer contacted to collect order

Third Contact

Staff Name

Staff Name

Staff Name

Date

Date

Date

Start Assessment

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- Step 1 of 3

Patient Name *

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction to any acne treatments before? *

Yes
No

If yes, please describe the product and the reaction

Do you have any allergies? *

Yes
No

If yes, please provide details

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy) *

Yes
No

Are you breast feeding? *

Yes
No

Have you started puberty? *

Yes
No

Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment? *

Yes
No

Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea? *

Yes
No

Are you currently using any other treatments for acne? *

Yes
No

Have you recently received an acne treatment containing antibiotics? *

Yes
No

If yes, please list the product and date you received it

If you have used acne treatments before, did you experience any side effects or skin irritation? *

Yes
No

If yes, please provide details

Do you have a history of photo-allergy (skin reactions in the sunlight)? *

Yes
No

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

Yes
No

Have you or any of your close family had skin cancer? *

Yes
No

Do you currently have sunburn, broken skin or abraded skin? *

Yes
No

Do you have any allergic diseases such as asthma, eczema or rhinitis? *

Yes
No

If yes, please provide details

Do you have any liver or kidney problems? *

Yes
No

If yes, please provide details (copy)

Are you currently using any cosmetics, medicated cleansers or scrubbing solutions? *

Yes
No

Do you suffer from severe psychological distress because of your acne? *

Yes
No

Have you undergone or recently undergone procedures such as depilation, chemical hair treatments, chemical peels, dermabrasion, laser resurfacing of the skin or phototherapy? *

Yes
No

Are you sensitive to sunlight or do you have considerable sun exposure? *

Yes
No

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for)

Complete Patient Details

Title *

Mr
Miss
Ms
Mrs
Other

Patients Name *

First

Last

Date of Birth (DD/MM/YYYY) *

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient GP Consent *

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent (Other) *

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions.

Patient ID *

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required *

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)