Q No.QuestionAnswer1 Are you pregnant or breastfeeding? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Have you been diagnosed with dry skin or eczema? If you have a rash that is new or undiagnosed it is best to see a doctor. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Do you have any problems with your liver or kidneys? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Are you aware you need to see a doctor about new rashes, worsening rashes or rashes not responding to treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Are you aware some emollients and emulsifiers are flammable and can make bathroom surface slippery? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Is your current flare up any different to past episodes of eczema or dermatitis? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Are you aware paraffin containing preparations can soak into clothing and bedding and cause a fire hazard? Avoid smoking and naked flames. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8Do you know that: You should always keep affected skin moisturised with an emollient cream or ointment You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Do you agree to the following? You will read the Patient Information Leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment The treatment is solely for your own use You are over the age of 18 and you have entered your own information for our identity verification checks You have answered all the above questions accurately and truthfully You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health You will inform your own GP of this purchase if appropriate You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions You must answer this question.You must answer this question.Please write your explanation in the box below Yes No10What 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
