Book A PrescriptionSkincare Consultation Please Fill Out The Form Below We offer a $70 bespoke program using scientifically backed ingredients which are tailored for your skin type!Please fill out the form with as much detail as possible and one of our consulting pharmacists will contact you via email. Your package will include advice and recommendations on: 1. Your current skincare. (ie. What to stop, what to continue) 2. Pharmaceutical/Prescription Day Cream 3. Pharmaceutical/Prescription Night Cream 4. Moisturiser and a sunscreen for your skin type If you are only requiring repeats from your previous consult, please call us on 07 3039 1589. For a follow up consult (>6 months) we will require updated photos. Please fill out the form below.Full Name(Required) First Last Your Email Address(Required) Your Phone(Required)Medicare Number Please tell us your occupation Date Of Birth DD slash MM slash YYYY Residential Address Street Address Suburb State Postcode Current Medications / SupplementsAny Medical ConditionsPregnant Or Breastfeeding Or Trying To Conceive ?Tell Us About Your Current Skincare- 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. Tell Us About Your Skin Goals- Please list the skin treatments you have received in the past 6 months. - Please specify, in as much detail as possible, your skin concerns and what you would like to achieve. Your Comments/QuestionsConsent(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.Skincare Consult Price: Total Credit Card / Debit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name
