| 1 | Are you aware you should see a doctor for a diagnosis of Rosacea BEFORE using Mirvaso gel?
You must answer this question. You must answer this question. | |
| 2 | Are you aware Mirvaso should be started carefully to avoid worsening rosacea?
You must answer this question. You must answer this question. | |
| 3 | Are you aware Mirvaso usually improves symptoms in 70% OF PEOPLE?
Mirvaso will not work for everyone.
You must answer this question. You must answer this question. | |
| 4 | Are you aware Mirvaso can actually worsen symptoms in some people (up to 16% of people)?
Worsening of redness can occur soon after Mirvaso is applied or later when the effects are wearing off (after 8 to 12 hrs). Most people recover on stopping treatment.
You must answer this question. You must answer this question. | |
| 5 | Have you been diagnosed with a medical condition causing significant low blood pressure?
This applies mainly to severe uncontrolled heart disease.
You must answer this question. You must answer this question. | |
| 6 | Are you taking an antidepressant of the following type?
- An antidperessant of the MAOI type (e.g. selegiline or moclobemide)
- A tricyclic antidepressant (such as imipramine) or tetracyclic (such as maprotiline, mianserin, or mirtazapin)
NOTE: Most antidepressants are NOT of these types. Please check with your doctor if you are not sure.
You must answer this question. You must answer this question. | |
| 7 | Have you been diagnosed with any of the following:
- Liver or kidney disease – no including simple water infections
- Sjorgen’s syndrome (uncommon immune condition causing dry skin)
- Poor circulation to the hands or feet
You must answer this question. You must answer this question. | |
| 8 | Are you pregnant or breast feeding or intending to become pregnant?
You must answer this question. You must answer this question. | |
| 9 | Are you aware Mirvaso should NOT be applied close to the eyes or lips or to open sores?
You must answer this question. You must answer this question. | |
| 10 | Are you aware Mirvaso should be stopped and a doctor consulted if symptoms are worsening or you experience side effects?
You must answer this question. You must answer this question. | |
| 11 | Do you have any further questions you need to ask?
You must answer this question. You must answer this question. | |
| 12 | Do all the following apply to you?
- The medication is for my own use
- I will read the information leaflet supplied with the medication
- I am over 18 and I agree to identity verification checks
- I have completed this questionnaire myself and fully understand all the information
- My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment
- I agree to the terms & conditions, privacy policy, & data sharing policy
You must answer this question. You must answer this question. | |
| 13 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
You must answer this question. You must answer this question. | |
