BOOK A DOCTOR CONSULT BOOK A DOCTOR CONSULT Please use this form if you require a script for: - discontinued medication - local anaesthetic cream or ointment - a unique compounded cream - excipients, flavours, preservatives to be ommited from your medication due to allergies or intolerances - any skin related conditions A doctor will be in touch within 48 hours. A $80.00 charge is associated with a doctor consult. Please note this is not redeemable with products or any other offers.Full Name(Required) First Last Your Email Address(Required) Your Phone(Required)Medicare NumberPlease tell us your occupationDate Of Birth DD slash MM slash YYYY Residential Address Street Address Suburb State Postcode List any current medications you are taking, including any over the counter prescriptionsList any medical conditions or skin treatments you have had in the past 6 months.Details of any allergies or restrictions if applicable.Are you pregnant, breastfeeding or trying to conceive?Upload Relevant Photos (Optional)Examples of relevant photos include packaging, existing medication, what you are currently using or taking, your skincare regime, photos of your skin or any information you think will assist with your consult.File Drop files here or Select files Max. file size: 10 MB. Any Additional Information You Would Like Us To KnowCAPTCHAConsent(Required) I agree to the privacy policy.I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of advice or treatment. I consent to My Skin Pharmacy using the information to provide the best possible outcome and I confirm that I have read and fully understand this consent form. In accordance with the privacy act (1988) all information collected is treated as "sensitive information". To protect your privacy, My Skin Pharmacy operates in accordance with the act. Australian Federal Privacy Laws require the pharmacy to receive your consent to collect your personal medical information.Your medical information will be used exclusively for the purpose of providing health care and treatment.Doctor Consult Price: Total Credit Card / Debit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
