Patient Information

Are you 12-65 years old?

Are you pregnant, trying to get pregnant, or breastfeeding?

Patient Symptoms

Do you have moderate to severe acne?

Medical History

Are you taking any of the following products?

• Topical products, like abrasive soaps and cleansers, cosmetics with strong drying effect, peeling agents
• Oral tetracycline antibiotics, like doxycycline and minocycline
• Any other treatment for acne
• Vitamin A supplements

Do you have any of the following?

• Mental condition, like depression, psychosis, or suicidal thoughts
• Liver disease
• Kidney disease
• High levels of cholesterol or fats in your blood
• High levels of vitamin A in your body (blurring of vision, drowsiness, irritability, abdominal pain, nausea/vomiting)
• Inflammatory bowel disease, like Crohn's disease or ulcerative colitis

Are you allergic to any of the following?

• Adapalene
• Azelaic Acid
• Benzoyl Peroxide
• Clindamycin
• Tretinoin
• Propylene Glycol

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment or worsening of your condition, if you start new medication, or if your medical conditions change during treatment
• You may experience skin dryness and sensitivity to the sun that may warrant you to use moisturizers and avoid overexposure to the sun
• The treatment is solely for your own use
• 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 understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber