Q No.QuestionAnswer1Are 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.Please write your explanation in the box below Yes No2Are you aware Mirvaso should be started carefully to avoid worsening rosacea? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Are 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.Please write your explanation in the box below Yes No4Are 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.Please write your explanation in the box below Yes No5Have 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.Please write your explanation in the box below Yes No6Are 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.Please write your explanation in the box below Yes No7Have 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.Please write your explanation in the box below Yes No8Are you pregnant or breast feeding or intending to become pregnant? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are 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.Please write your explanation in the box below Yes No10Are 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.Please write your explanation in the box below Yes No11Do you have any further questions you need to ask? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No12Do 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.Please write your explanation in the box below Yes No13What 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.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
