Acneclear Booking and Consultation Form Logo

  • Video Consultation & Medical History

    Please have photos of your acne and photos of your IUD implant (if applicable) ready to upload before you start. You will also need to know your current weight in kilograms. The form should take about 10 - 15 minutes to complete.

  • Our service is available only to patients who reside in the UK during treatment. We are not able to take any other patients under care who live outside the UK, as it involves the prescription of medications under UK jurisdiction. If you aren't resident in the UK, we regret we won't be able to help you so please do not proceed with your booking. Thank you for considering acneclear. 

  • Please select a preferred date and time for your virtual consultation. This is not a live booking, but rather tells us when you'd prefer to have your consultation. Our team will then contact you with the closest availability and a secure payment link. Once payment is made, your appointment confirmation will be sent to you. 

  • Medical History

    Make sure you have your photos ready to upload.
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  • Isotretinoin Pregnancy Prevention Programme Acknowledgement Form

     

    Isotretinoin can cause severe birth defects to an unborn baby if it is taken - even in small amounts - during pregnancy and there is an extremely high risk that you will have a severely deformed baby:

    • If you are pregnant when you start taking Isotretinoin
    • If you become pregnany while you are taking Isotretinoin
    • If you become pregnant within 1 month after stopping treatment with Isotretinoin

    Do not sign this acknowledgement form and do not take Isotretinoin if there is anything that you do not understand about the information you have received about using Isotretinon.

    The following points of information are clear to me:

    1. I understand that severe birth defects have occurred in babies of females who took Isotretinoin during pregnancy.
    2. I understand that I must not take Isotretinoin if I am pregnant.
    3. I understand that I must use at least 1 and preferably 2 separate, effective forms of contraception for at least one month before starting treatment, and throughout the treatment period and for at least one month after stopping the treatment. 
    4. I am fully aware of the risks of possible contraceptive failure.
    5. I agree to talk to my doctor about any medicines or herbal products such as St John's wort. 
    6. I understand that I should not start taking Isotretinoin until I am sure that I am not pregnant and have had a negative pregnancy test if I am at risk of becoming pregnant.
    7. I understand that I may require monthly pregnancy tests during my treatment with Roaccutane and that my doctor will discuss this with me during each follow up visit. 
    8. I understand that I will have to have a pregnancy test 5 weeks after stopping Isotretinoin therapy if I am at risk of becoming pregnant.
    9. I have read and understand the following materials: The Patient information brochure and the Brochure on contraception.
    10. I understand that I must stop taking Isotretinoin right away and contact my doctor or consultant or GP if I get pregnant, miss my period, stop using contraception methods, or have sex without using contraception during my treatment with Isotretinoin or in the month after I have stopped taking Isotretinoin. 
    11. I understand, if I become pregnant my doctor may refer me to a physician specialised or experienced in birth defects for evaluation and advice. 

    I understand the risks and precautionary measures involved.

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  • Isotretinoin Therapy
    Terms, Conditions, and Consent Form

    Please read this document carefully before starting your Isotretinoin therapy with us. By signing below, you confirm that you understand and agree to the terms, conditions, and consent requirements outlined herein, which are designed to ensure the safe, efficient, and effective management of your treatment.

    1. Treatment Adherence and Progress

    Isotretinoin therapy requires adherence to the prescribed dosage schedule to achieve the target cumulative dose within the specified Days Under Care (DUC).

    • Treatment Extension: You may take up to 10% longer than the quoted DUC without incurring additional charges. If deviations such as taking less than the prescribed dosage, pausing treatment, or other non-compliant actions result in exceeding the allowed 10% extension, additional charges will apply. These charges will cover extra appointments, administrative costs, and the continued time under care.

    2. Patient Compliance

    Your compliance is critical to the success and safety of your treatment. This includes:

    • Booking and attending scheduled appointments
    • Completing required blood tests
    • Providing photographic evidence of pregnancy tests (where applicable)
    • Acknowledging dosage advice promptly
    • Non-Response Policy: If you fail to respond to our communications after three documented attempts requesting your response, we reserve the right to discontinue your treatment and discharge you from our care without a refund.

    3. Communication and Address Updates

    You are responsible for keeping your contact information, including your postal address, email address and phone number, current and up to date.

    • Address Changes: If you change your address, you must notify us immediately. Failure to do so may result in medication, postal kits, or skincare products being sent to the wrong address. In such cases, a replacement fee will be charged to resend any items delivered to an incorrect address due to outdated information.

    4. Refund Policy

    There are no refunds once treatment has commenced. This policy includes, but is not limited to, situations where treatment is extended due to patient non-compliance or pausing of treatment initiated by the patient. Payment plans must be completed in full, even if the patient abandons treatment for any reason.

    5. Consent to Treatment and Understanding of Risks

    • I confirm that the Specialist has provided me with sufficient information to understand the treatment, including its approved indications, contraindications, and potential undesirable effects.
    • I have been given the opportunity to ask all questions regarding the treatment, and my questions have been answered to my satisfaction.
    • I have provided accurate and complete information in my medical history to the best of my ability.
    • I understand that Isotretinoin treatment can have serious side effects, which have been explained to me. Once I begin treatment, I commit to completing the course unless discharged earlier for medical reasons.

    6. Use of Photographs

    • I consent to the storage of my photographs for diagnostic purposes and to enhance medical records. These photographs will remain the property of AcneClear. I consent to their use in medical, scientific, or other publications and presentations, as well as marketing and website information, with respect to my patient confidentiality.

    7. Acknowledgement of Risks and Limitations

    • I understand the risks and possible consequences involved in the treatment, and I acknowledge that no warranty or guarantee has been made regarding the results or cure. I recognise that dermatology is not an exact science and that reputable specialists cannot guarantee specific outcomes.
    • I hereby authorise the Specialist to administer treatment and agree to hold them free and harmless from any claims or suits for damages arising from any injury or complications that may result from this treatment.

    By signing below, I confirm that I have read, understood, and agree to these terms and conditions, and that I consent to the treatment as outlined above.

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