RETURNING CUSTOMER RETURNING CUSTOMER Step 1 of 3 33% Requesting On Patient's Behalf As A Clinic?YES, 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 followup consultation on their behalf.Person In Charge Of Product Payment(Required) First Contact Number For Product Payment(Required)Patient DetailsPlease choose one of the following services.(Required) Request 6 month review Reorder products from previous consult Full Name(Required) First Last Contact Number(Required)Email(Required) Postal Address for delivery of products(Only required if details have changed since your last consultation.) Street Address Suburb State Postcode How would you like to receive advice?(Required) Email (+ Option Of A Phone call) At Pharmacy (530 Milton Road, Toowong) A booking calendar will be sent to you seperately. Are you happy with your current routine?Are there any new products or ingredients you would like to try?Do you have any other comments or questions for our pharmacist?Has your medical condition(s) or medication(s) changed since your last consult? Please provide details below.Are You Pregnant/Breastfeeding/Trying To Conceive ?(Required) Yes No N/A (Please note: If you become pregnant, please stop treatment and let our team know.)Please Specify Pregnant Breastfeeding Trying to conceive Undergoing fertility treatments To help select the best treatment options, we recommend updated photos.- Please upload THREE relevant pictures in natural lighting showing different angles. (i.e.one front profile, one left profile and one right profile)File Drop files here or Select files Max. file size: 10 MB. Are you happy for us to use your before after pictures anonymously (eyes blacked out) to help others out?(Required) Yes, I am happy to help others. No thank you. Consent(Required) Enjoy your consultation. 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.CAPTCHAConsultation Fee Price: Total