1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Details & PaymentBefore you start, it is important that you read this:Welcome to our online clinic. This assessment forms the basis of today's consultation. We need you to be honest with your answers so our doctor can prescribe medication safely and give you the right advice. If you forget to tell us something or give inaccurate information, we may prescribe a drug that can harm rather than help you. It's important that you tell us about any medication you are already taking when we ask for this.I agree to answer questions honestly and fullyYesNo Your ConditionHow long have you had acne?*Less than a month1-6 Months6-12 MonthsOver a yearWhich parts of your body are affected by acne?* Face Neck Shoulders Chest Back Other AreasWhich of the following best describes your acne?*Mainly blackheads or whiteheadsMainly inflamed spots (zits)Tender lumps under the skinHave you previously been treated for acne?*NoYesWhat treatments were you prescribed?*Your HealthDo you have any other skin problems such as eczema, rosacea, perioral dermatitis or cutaneous epithelioma?*NoYesAre you currently taking any prescription-only medicines, alternative medicines or recreational drugs?*NoYesPlease provide information*Do you have any other health problems or conditions that you think we should know about?*NoYes(e.g. Myasthenia Gravis, systemic lupus erythematosus (SLE), G6PD, or recent major operations etc.)Please provide information*Are you pregnant or planning to become pregnant or breastfeeding?*NoYesN/APlease provide information*ConsentI agree to the site's terms and conditions. I confirm I am over 18 years old. The medicine ordered is for my sole use only. I will read the patient information leaflet supplied with the medicine or obtain it from the website; I will especially take note of the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.*NoYes I Agree Choice of Medication*Differin Cream 45g - £ 24.95Differin Cream 90g - £ 48.00Differin Gel 45g - £ 24.95Differin Gel 90g - £ 47.95Duac Gel (25g) - £17.95Duac Gel (50g) - £31.75Duac Gel (75g) - £41.75Lymecycline 408mg Capsules (28) - £14.50Lymecycline 408mg Capsules (56) - £22.50Lymecycline 408mg Capsules (84) - £31.95Oxytetracycline antibiotics (336) (3 Month Supply) - £38.95Prescription Charge £ 5.00Total £ 0.00 Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.