Online Consultation Form

1
Date of Birth* This field is required.
Date
Day
Month
Year
2
About You* This field is required.
Title
First Name
Last Name
Preferred Name
Please Select
Please Select
Male
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Non-binary/non-conforming
Gender
Please Select
Please Select
Not applicable
Male
Female
If different from your gender identity, what was your sex at birth?
3
Your Contact Details* This field is required.
Email
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4
Address* This field is required.
Street Address
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United Kingdom
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Afghanistan
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Country
5
Newsletter
Please email me City Skin Clinic special offers & tips.
6
Emergency Contact* This field is required.
Emergency Contact Name
Emergency Contact Number
7
GP Details* This field is required.
GP Name
GP practice name
GP practice phone number
8
Which of these do you need help with? Please select all that apply.* This field is required.
My Skin
My Hair
9
Where are you experiencing hair loss on your head? Please select all that apply.* This field is required.
Along the Hairline
At the Crown (top of the head)
All over
10
How much hair have you lost? Please choose one.* This field is required.
A little bit (only I notice it)
A fair bit (my friends & family have noticed)
A lot (everyone notices)
11
How long have you had your hair loss for and has it changed over time?* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
12
What improvements do you wish to see?* This field is required.
Reduce shedding
Regrow my hair
Prevent future hair loss
Something else
13
Please tell us what other improvements you're hoping to see.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
14
Do you have any of these symptoms? Please select all that apply.* This field is required.
Severe itching, burning, or rash on my scalp
Severe pain, pimples, pus, bumps, or sores on my scalp
Loss of brows, lashes, facial or body hair
None of the above
15
Please tell us about these additional symptoms.* This field is required.Provide as much detail as possible including how long you have had them, treatments you've tried for them and if they're getting better.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
16
Have you tried any hair loss treatments before?* This field is required.
YESNO
17
Which treatments have you tried? Please select all that apply.* This field is required.
Minoxidil
Finasteride
Dutasteride
Spironolactone
Something else
18
Please tell us about the treatments you've tried before.* This field is required.Give as much detail as possible including treatment type, strength, how long you used it for and what your experience was of it.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
19
Please describe what you currently use for hair care or styling (e.g. shampoo/conditioner, hair oils, treatments, styling products or tools).* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
20
Is anyone in your household currently pregnant, breastfeeding, or actively trying to get pregnant?* This field is required.Finasteride and/or Dutasteride is a Category X teratogenic medication that may potentially harm a male foetus if ingested or absorbed through the skin of a pregnant female. We will not include Finasteride, Dutasteride or Tretinoin in any hair loss treatments if you or someone in your household is pregnant or breastfeeding.
YESNO
21
I agree to let my doctor know if I or anyone in my household becomes pregnant or starts actively trying if I am on Tretinoin, Finasteride and/or Dutasteride.* This field is required.
Yes, I will let my doctor know.
No, I can't promise this and do not want to be prescribed Finasteride and/or Dutasteride.
22
Do you have a history of depression?* This field is required.Certain ingredients can no be used in people with a history of depression as they may trigger or worsen this.
YESNO
23
Do you have any customisation requests? Please let us know if there are any particular ingredients or preferences you have for your treatment.* This field is required.We will do our best to accommodate your wishes as long as we feel it will be safe and effective for you.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
24
Is there anything else you would like to share with your doctor about your hair loss?
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
25
Which of these areas of your skin are you most concerned about? Please select all that apply.* This field is required.
Forehead
Cheeks
Nose
Around mouth
Jawline
Chin
Neck
Something else
26
Please tell us which other areas you're concerned with.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
27
What are your main skin concerns? Choose as many as you’d like.* This field is required.
Acne
Fine lines & wrinkles
Hyperpigmentation (dark spots or marks)
Melasma
Large pores
Acne scars
Rough skin texture
Dull skin
Rosacea
Prevent skin ageing
Something else
28
Please tell us what else you're concerned about.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
29
How long have you had your skin problem(s) for and has it changed over time?* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
30
What specific improvements do you wish to see?* This field is required.
Tackle lines and wrinkles
Clear up acne and reduce breakouts
Smoother skin
Brighter complexion
Even out skin tone
Prevent skin ageing
Something else
31
Please tell us what other improvements you're hoping to see.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
32
Have you previously used any prescription skin products?* This field is required.
YESNO
33
Please tell us which prescription products you used and your experience of them.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
34
How would you describe your skin type? Please select all that apply.* This field is required.
Oily
Dry
Combination
Normal
Sensitive
Something else
35
If there's something else please tell us what.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
36
Have you ever had irritation or any problems when using new skincare products?* This field is required.
YESNO
37
Tell us about what problems you had and which products caused them.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
38
Tell us about your daily skincare routine. Please include which products and brand(s) of skincare you are currently using in your skincare routine.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
39
Are you currently receiving or planning to have any aesthetic treatments (e.g facials, chemical peels, Botox, Fillers, PDO threads, surgery or laser)?* This field is required.
YESNO
40
Please tell us which treatments you've had or are planning to have and when your last one was/when you are planning to have the next treatment.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
41
How much Sun/UV exposure do you have now and how much have you had in the past?* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
42
Do you do anything else for your skin (e.g. at home peels, face masks, LED masks etc...)* This field is required.
YESNO
43
Tell us a little about this treatment and how often you do it.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
44
Are there any particular skincare ingredients or treatments you are interested in?* This field is required.We will always try to accommodate your preferences if your doctor feels that it would be safe and effective for you.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
45
Do you have any concerns or expectations regarding any aspect of our skincare treatments?* This field is required.
YESNO
46
Please tell us what you're concerned about.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
47
Is there anything else you want us to know?
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
48
Do you suffer from any of the following conditions? Please select all that apply.* This field is required.
Skin diseases (e.g. eczema, psoriasis, rosacea)
Hair diseases (e.g. alopecia)
Kidney disease
Polycystic Ovarian Syndrome (PCOS)
Epilepsy
Diabetes
Heart Disease
High blood pressure (Hypertension)
Chronic lung disease
Immunodeficiency
Thyroid problems
Thread veins/varicose veins
Cancer under active treatment
None of these
49
Do you have any other health conditions?* This field is required.
YESNO
50
Please tell us about any other medical problems you have.* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
51
Do you have perimenopause or menopause?* This field is required.
YESNO
52
What effects do you feel perimenopause or menopause have had on your skin and/or hair?* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
53
Are you pregnant or breast feeding (or planning to be in the near future)?* This field is required.
YESNO
54
Are you currently receiving any medical treatment or on any medications?* This field is required.
YESNO
55
Please list any treatments/medicines you're taking* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
56
Do you have any allergies?* This field is required.
YESNO
57
Please tell us about your allergies including what caused them, what happens and if you have ever had anaphylaxis?* This field is required.
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
58
Do you smoke?* This field is required.
YESNO
59
Do you drink alcohol?* This field is required.
YESNO
60
Your Baseline Photos* This field is required.Please upload AT LEAST 3 photos of your whole face and neck without makeup (one straight on, one showing left and one showing right side). For hair loss, please also include a photo of the top of your head so we can see hair loss at the crown. If the area you're looking to treat is not on the face or neck please also attach photos of that region IN ADDITION to the photos of your face. These will be used to assess your skin and design your treatment protocol as well as monitor your progress. If the photos attached are blurry/unclear, incomplete or cropped then your doctor will ask you to email another set.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Remember, you can save your form at any time by clicking the save or number button at the bottom of the screen.
Cancelof
61
Please review our consent form & policies* This field is required.I understand that my assigned doctor will use the information provided in this consultation to create a treatment protocol including products at concentrations and frequencies they deem safe and appropriate for me. They will email me this protocol and may request additional information from me regarding my skin or health background if needed. Possible Risks & Side-Effects of Skin & Hair Treatments: GENERAL SIDE EFFECTS OF ALL TREATMENTS I am aware that there is a possibility of side effects with any treatment. I understand that general normal skin reactions when initially starting new skincare include irritation, redness, dryness/flakiness/peeling, skin sensitivity, purging (breakouts of spots) and tight feeling of the skin. People with sensitive skin might become excessively red, swollen, blistered or crusted. In very rare cases some people may experience hyperpigmentation (dark patches) or hypopigmentation (light patches) when using active skincare. I also understand that common reactions when starting a new topical hair loss treatment include itching, irritation, flaking, hair shedding and unwanted hair loss. In rare cases some people may experience dizziness or palpitations. Some people may experience changes in hair texture/colour. I understand that for the majority of people the above reactions last for a short period and usually subside in the first 4-6 weeks of treatment. However in a small minority of cases these may last longer. In either case, I will let my doctor know immediately if I experience any adverse side-effects (no matter how mild) so that they can advise me on how to manage these. SPECIFIC SIDE EFFECTS FOR PRESCRIPTION INGREDIENTS TRETINOIN is a prescription-only active ingredient and can’t be used in pregnancy or breastfeeding (or those planning to be) due to the risk of congenital abnormalities in infants. It can cause skin irritation and increased breakouts especially in the first month of use. Tretinoin also causes photosensitivity so it is important to use adequate sun protection when using it. HYDROQUINONE can cause irritation and hypopigmentation. There is also a risk of rebound hyperpigmentation if used without adequate sun protection. Hydroquinone can also cause ochronosis. This a blue-black or grey-blue discolouration. This is rare and more commonly seen in patients that use a high concentration of hydroquinone for a long period on large areas of the body. CLINDAMYCIN may cause dryness, itching, or redness. In rare cases, clindamycin can cause more severe reactions like gastrointestinal issues if it is absorbed systemically. If you experience severe irritation or an allergic reaction, discontinue use and seek medical help. METRONIDAZOLE can cause side effects such as nausea, diarrhoea, stomach pain, dizziness and metallic taste in the mouth. It may also lead to more serious reactions like allergic responses or seizures in rare cases. IVERMECTIN can cause side effects such as dizziness, nausea, diarrhoea and itching. In rare cases, it may lead to more severe reactions like low blood pressure, seizures, or liver injury. AZELAIC ACID can cause side effects such as mild burning, stinging, or tingling of the skin, itching, and dryness. In rare cases, it may lead to severe skin irritation or allergic reactions. SPIRONOLACTONE may cause dizziness, lightheadedness, increased urination, increase in potassium, breast tenderness, irregular periods or lack of menstrual periods, breast enlargement, breast tenderness, and feeling faint or passing out. HYDROCORTISONE may cause side effects such as skin thinning, redness, and increased hair growth on treated areas. Prolonged use may lead to stretch marks, skin discoloration, and increased susceptibility to infections. MINOXIDIL can cause side effects such as scalp irritation, itching, and dryness. Unwanted facial hair growth may occur, and in rare cases, it can lead to dizziness, heart palpitations, or chest pain. FINASTERIDE/DUTASTERIDE these can cause scalp irritation, itching and redness. In rare cases it can lead to depression or allergic reactions. Whilst topical Finasteride and Dutasteride have lower risks than oral medicines, there are still some serious potential side effects to be aware of. These include depression or mood changes, decreased libido, erectile dysfunction, and ejaculation disorders, which can be long-term even after discontinuing medication. Additional side effects for both medications include breast tenderness, enlargement (gynaecomastia), lumps and discharge. There is also a risk of severe allergic reactions. Both drugs pose significant risks during pregnancy, as they can cause birth defects in male foetuses, making them unsuitable for women who are or may become pregnant. Other reported side effects include dizziness, depression and changes in PSA levels which can mask prostate cancer. Treatment Protocol: In order to get the most out of your treatment and reduce risks of side effects, you will need to follow your treatment protocol and update your doctor of your progress. In starting treatment with us you agree to the following: I will comply with the programme outlined by my doctor and any adjustments made to my protocol as my treatment progresses. I understand the above potential risks and side-effects and I agree to immediately let my doctor know if any of these occur. I understand that the recommended treatment programme is usually for a minimum of 3-6 months as this is usually the average amount of time needed to start to see results for my skin or hair concerns. However this may be longer depending on my concern. I will protect my skin from the sun using a broad spectrum sunscreen of at least SPF30 everyday and clothing whilst on treatment and after. I acknowledge that if I do not protect my skin from the sun then my treatment outcomes might be impaired and in the case of Hydroquinone I may experience rebound hyperpigmentation which may reverse any improvements I have gained. I am aware that even if an expected time to treat my concerns is outlined by my doctor, this may be subject to change depending on how my skin/hair responds. I accept that results may vary from person to person and that no guarantees can be made of efficacy or the time taken for skin or hair to respond to treatment. I agree to virtual assessments are needed to monitor the changes in my skin/hair and to discuss my progress to ensure my individual needs for my skin are addressed. I understand that my treatment will be fully documented throughout and photos will be requested to monitor my progress. I agree to inform City Skin Clinic of any changes to my health that could affect my treatment. I agree to let my doctor know if I suffer from eczema, fish allergy or have any sores, burns or wounds. I agree that if I become pregnant whilst on my treatment plan, I'll need to stop using it immediately and let City Skin Clinic know so that my doctor can advise on what I can use instead that is considered safe in pregnancy. I will stop using the products and let my doctor know immediately if I develop an allergy or reaction to any of the products I am recommended. I am not aware of any allergies to any of the actives on the ingredients page or any other skincare or hair products other than the ones I have mentioned above in the allergies section. General Policies: I understand that the the safety and efficacy of the treatments recommended by City Skin Clinic have not been established in patients younger than 12 years of age. Nor are they recommended for use by pregnant or breast feeding women. I agree that I will only use the products for myself as directed by my treating practitioner and keep them out of the reach of children, animals or vulnerable people. I understand that compounded treatments are unlicensed medications because they are custom-made for each patient based on a specific formulation tailored to their unique needs. Unlike licensed medications, compounded treatments are created by pharmacists to meet the specific requirements of an individual patient as prescribed by their doctor. As such they do not undergo the same approval process as licensed medications. I understand that neither the individual doctor nor Brainworks Interactive Limited (trading as City Skin Clinic) will be liable for any adverse reactions as a direct or indirect result of my non-disclosure of any relevant facts or information requested during the consultation. I accept that the £30 consultation fee is for the doctor to create a protocol for me with the recommended products to address my concerns based on the information I have provided. There is no obligation to purchase any products or to continue treatment. This fee is for the consultation only and is not refundable. However it will be deducted from the cost of any treatments I purchase. I accept that any treatments recommended will be from the list on the treatments menu (you can find our treatment menu here) which also lists the full fees for each treatment. The doctor will take into account any preferences that I have expressed but will only prescribe and recommend treatments that they deem will be safe and effective for me. I have read the above consent form provided by Brainworks Interactive Limited (trading as City Skin Clinic) including the risks associated with the treatment and I agree to send updates and photographs before, during and after treatment for record-keeping and progress monitoring. I permit the use of any testimonials that I post on third party websites or send to you directly for use in marketing. I acknowledge and agree that if I choose to accept the treatment protocol and wish to purchase the recommended product(s), I will be responsible for and will pay all charges, which are contained in the applicable invoice issued by Brainworks Interactive Ltd (trading as City Skin Clinic). I agree by submitting this form that I will be bound by the terms of business. You can find our terms of business here. I understand that any data I share will be held and used in line with the privacy policy. You can find our privacy policy here.
I have read and accept the above.
I confirm that all the information provided is true and accurate and that any treatment prescribed will only be used by myself.
I understand that hair loss and skin treatments from City Skin Clinic can't be used if I am pregnant or breastfeeding and I agree to let my doctor know if this changes or if someone in my household becomes pregnant/breastfeeding. You can ask your doctor for more info regarding this.
62
Do you permit the use of anonymised images from your photographs for use in marketing?* This field is required.
Please Select
Please Select
Yes
No
63
Signature* This field is required.
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64
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Online Consultation FeeThe £30 consultation fee is is needed for our doctors to review your form and create a personalised treatment plan. This fee is not refundable but can be redeemed against any treatments you purchase.
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