Online Skin Assessment

1
Legal Name* This field is required.A legal name is a requirement for the fulfilment of any prescription items. If you prefer to be known by a different name, please let us know in the 'preferred name' section.
Title
First Name
Last Name
2
Preferred Name
First Name
Last Name
3
Date of Birth* This field is required.
You must be aged 18 years + to access our services
Day
Month
Year
4
Biological Gender* This field is required.
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Please Select
Female
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5
Are you currently pregnant, breastfeeding, undergoing fertility treatment or trying to conceive?* This field is required.
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Please Select
Yes
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6
Please specify:* This field is required.
I am currently pregnant.
I am currently breastfeeding.
I am undergoing fertility treatment.
I am actively trying to conceive.
7
Email* This field is required.
example@example.com
8
Contact Number* This field is required.
Please enter a valid phone number.
9
Address* This field is required.
Street Address
Street Address Line 2
City
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United Kingdom
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Afghanistan
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Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
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New Caledonia
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Niger
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Niue
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Poland
Portugal
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Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
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Samoa
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Saudi Arabia
Senegal
Serbia
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eSwatini
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Other
Country
10
How did you hear about us?* This field is required.
Referral from a friend/family member
Instagram
Facebook
Google Search
Other
11
I'd like to stay up to date with the latest news, updates & exclusive discounts.* This field is required.Newsletter Signup
Yes, count me in.
Maybe another time.
12
What is your main skin concern?* This field is required.
I want to clear my acne (whiteheads, blackheads, pustules).
I want to treat dark marks left after acne has healed.
I want my skin to appear firmer and smoother.
I want to improve fine lines, wrinkles and early signs of ageing.
Other
13
Which of these best represents your skin type? These options are based on the Fitzpatrick Scale, a widely recognised medical classification scheme for skin of colour.* This field is required.
Type I – Pale skin, always burns, never tans.
Type II - Fair skin, burns easily, tans minimally.
Type III - Darker white skin, sometimes burns, slowly tans to light brown.
Type IV - Light brown skin, burns minimally, tans easily.
Type V - Brown skin, rarely burns, tans well.
Type VI - Dark brown or black skin, never burns, always tans easily.
14
Which of these options best describes how your skin feels?* This field is required.
My face often feels dry, tight & dehydrated – it is uncomfortable without the use of a good moisturiser.
My face feels oily – I tend to opt for mattifying skincare products.
My face feels oily in some parts (usually nose, chin & forehead) but dry in other areas.
My face feels well balanced, neither too oily nor too dry.
15
How sensitive is your skin?* This field is required.
It’s not sensitive at all, I never have problems with skincare products.
It’s usually fine, but it can be sensitive to acids or active ingredients.
My skin is regularly quite sensitive to a lot of skincare products.
16
Please outline all the products you currently use in your morning skincare routine, including brand specific details (e.g Cetaphil Gentle Cleanser).* This field is required.
17
Please outline all the products you currently use in your evening skincare routine.* This field is required.
18
Please outline all other skincare products you use e.g on a weekly/monthly basis.* This field is required.
19
Are you currently under the care of your GP, dermatologist or other healthcare professional for any skin condition?* This field is required.
Please Select
Please Select
Yes
No
20
Please provide any details relevant to their care.
21
Have you previously been under the care of your GP, dermatologist or other healthcare professional for any skin condition?* This field is required.
Please Select
Please Select
Yes
No
22
Please provide any details relevant to their care.
23
Are you currently using prescription-strength skincare, such as tretinoin, azelaic acid, steroid creams, hydroquinone etc?.* This field is required.
Please Select
Please Select
Yes
No
24
Please outline which prescription skincare treatments you are currently using.* This field is required.
25
Are you currently taking any oral medication for a skin condition? For example antibiotic tablets or isotretinoin (Roaccutane) for acne.* This field is required.
Please Select
Please Select
Yes
No
26
Please outline which oral medication you are currently taking?* This field is required.
27
Have you previously used any prescription-strength treatment for a skin condition? This includes any topical skincare such as medicated creams or oral tablets e.g antibiotics, Roaccutane etc?* This field is required.
Yes
No
28
Please outline which treatments you have trialled previously (Where possible, please include when you were prescribed it, the duration and how effective it was).* This field is required.
29
Have you previously used any non-prescription retinoid (e.g retinol)?* This field is required.
Yes
No
30
Please outline which retinol products you have trialled previously and how effective they were.* This field is required.
31
Have you previously suffered with any of the following skin conditions?* This field is required.
Acne
Rosacea
Eczema
Hyperpigmentation
Hypopigmentation
Skin Cancer
Psoriasis
Other
32
Are you currently taking any prescribed medication?* This field is required.
Yes
No
33
Please list the names and doses of all medications.* This field is required.
34
Do you have any medical conditions?* This field is required.
Yes
No
35
Please list all your medical conditions.* This field is required.
36
Do you use any medications bought 'over the counter' such as paracetamol or ibuprofen?* This field is required.
Yes
No
37
Please list the names and doses of all 'over the counter' medications.
38
Do you regularly use any herbal supplements or vitamins?* This field is required.
Yes
No
39
Please list the names of all supplements or vitamins.
40
Are you allergic to any medicines (e.g penicillin, tretinoin, benzoyl peroxide) or substances (e.g soya, nuts)?
Yes
No
41
Please outline all medicines/substances you are allergic to and the reaction if known.
42
We will provide you with all recommended treatment options based on your answers, however if you have a particular preference for a treatment please outline below.
Adapalene (prescription strength retinoid)
Tretinoin (prescription strength retinoid)
Azelaic acid (prescription strength 15% or 20%)
Custom prescription skincare (bespoke formula)
Other
43
Please detail any further information which you feel may be relevant for your asssessment.
44
We require clear photos as part of our review process. Please upload at least 3 photos of your whole face from different angles (one front-facing, and one of each side of your face). You can inidividually upload photos directly from your mobile camera.

When uploading your photos please make sure:

1) You are not wearing any makeup
2) There are no filters on the camera or photos
3) You are in a well-lit room and your skin is clearly visible

All photos and data we collect is always treated confidentially. You can find more information on our commitment to confidentiality as part of our Terms and Conditions & Privacy Policy.
45
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Terms and Conditions* This field is required.
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Terms and Conditions* This field is required.
48
Terms and Conditions* This field is required.
49
Terms and Conditions* This field is required.
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Thank you, that's everything!

What happens next?

You will shortly receive an email confirming receipt of your assessment. Please check your Junk folder & make sure to add us to your safe senders list so you do not miss out on important updates.

Our Prescribing Team will review your assessment within 3 working days. If we require any further information, we will contact you via email or WhatsApp.

If you need to contact us in the meantime, please email info@pharmaskin.co.uk.

Thank you for choosing PHARMASKIN.
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