BOOK A FREE SKINCARE CONSULT BOOK A FREE SKINCARE CONSULT Step 1 of 4 25% Requesting On Patient's Behalf As A Clinic?REQUESTING ON PATIENT'S BEHALF AS A CLINIC YES, REQUESTING ON PATIENT'S BEHALF AS A CLINIC Clinic DetailsClinic Name(Required) First Consent(Required) I have permission from the patient to request a consultation on their behalf.Person In Charge Of Product Payment(Required) First Contact Number For Product Payment(Required)Patient DetailsPatient Type(Required) I am a new patient I am a returning patient Full Name(Required) First Last Email Address(Required) Contact Number(Required)Medicare Number(Required)How did you hear about us? Word of mouth Google search Instagram/Facebook/Social Media Group Referred by a friend using My Skin How would you like to receive correspondence?(Required) Email Recommendation (+ Option Of A Phone Call) At Pharmacy (530 Milton Road, Toowong) A booking calendar will be sent to you seperately. Friend's Name Tell Us More About You:Date Of Birth(Required) DD slash MM slash YYYY Please tell us your occupationPostal Address for delivery of products(Required) Street Address Suburb State Postcode Are You Pregnant/Breastfeeding/Trying To Conceive ?(Required) Yes No (Please note: If you become pregnant, please stop treatment and let our team know.)Please Specify Pregnant Breastfeeding Trying to conceive Undergoing fertility treatments Tell us about your skin journey so far:Have you had a skin cancer checkup in the past 12 months?(Required) Yes No Do you have a family history of breast cancer or any other type of cancer? If so, please specify your relationship to the affected individuals. Yes No Type of cancer.Relationship to the affected individuals.Have you ever been prescribed treatment for: Acne Allergic Skin Dermatitis/Perioral Dermatitis Pigmentation/Melasma Psoriasis Rosacea Skin Allergy Other Please ListDo you use the following in your daily skincare routine? Cleanser Toner Moisturiser Serums Sunscreen Please provide details of productsHave you ever had a reaction to a skincare product? If so, please specify and describe reaction:Current Medications and/or Medical ConditionsHave you ever had an allergic reaction to a medication? If so, please specify and describe reaction:Have you received any of the following treatments in the past 6 months? Chemical Peels Cosmetic Tattoo Facials Laser IPL Microdermabrasion Microneedling Other Please List Tell Us About Your Skin GoalsWhat improvements would you like to see?I am open to trying: Prescription skincare AHA/BHA creams Estriol face creams A new wash and moisturiser A new suncreeen Anything (Try me!) Please chose as many asI am also open to trying the following brands: Biopelle Dermaceutic La Roche Posay - Please upload ONE photo of your skincare in order of application. (ie. cleanser, actives, moisturiser, SPF) - Please upload THREE pictures of your face in natural light no makeup (one front profile, one left profile and one right profile)File Drop files here or Select files Max. file size: 10 MB. CAPTCHAConsent(Required) Please carefully read the privacy information below.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. Our doctors will only prescribe treatment if remote prescription treatment is safe and appropriate for you. A treatment is not guaranteed. 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.Consultation Fee Price: Total
