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Skin Concerns Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

Order #*

Please enter the order number found on the Order Confirmation email that you received. Your information will only be viewed by our Medical Team and is stored on HIPAA compliant servers.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Are you allergic to any medication? *
What medications or vitamins are you taking? *
What is your date of birth? *
Gender* Female Male
What skin concerns are you experiencing? (select all that apply) *
Acne
Anti-Aging/Wrinkles
Sun Spots/Uneven Skin Tone
Eczema
Psoriasis
Dermatitis
Redness and inflammation
Rough Texture
Cracked Skin
Other
Please describe your condition in detail. (The more you tell us.... the more we can help!) *
Duration of Condition (Weeks, Months, Years) *
Have you used any product/treatment in the past for this condition? *
Yes No
Please check what products you have used to treat your skin care concern(s)? *
Tretinoin
Benzoyl Peroxide
Hydroquinone
Vitamin C
Kojic Acid
Diphenhydramine (Benadryl Cream)
Other
None
"How long did you use it? (enter number of weeks, days, or months) *
"Was it Effective?" *
Yes No
Why do you Feel it was not effective? *
Did you experience any side effects? * Yes No
Please explain what type of side effects you experienced. *
Have you been diagnosed with or are currently being treated for any of the following: *
Actinic Keratosis
Anesthetic Complications
Artificial Heart Valve
Artificial Joint (Within Past 6 Months)
Asthma
Autoimmune Disease
Cancer (other than skin cancer)
Childhood Eczema
Diabetes
Heart Attack or Stroke
Hepatitis C / Liver Disease
High Blood Pressure
HIV/AIDS
Keloid
Kidney Disease
Melanoma
Mental Disorders and Conditions
Organ/Bone Marrow Transplant
Pacemaker/ Defibrillator
Psoriasis
Seasonal Allergies/Hay Fever
Skin Cancer
Thyroid Disorders
None Apply
Are you pregnant or nursing or planning to become pregnant? *
Yes No
In the near future, do you plan on becoming pregnant or nursing? *
Yes No
Please list what you take or method of birth control. *
Date of your last physician exam?
Name of your primary physician

Note: Your medical information will not be saved until you click on the SUBMIT button.

We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Note: Your medical information will not be saved until you click on the SUBMIT button.