Consultation form with conditional logic

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Please complete this questionnaire as thoroughly as possible to help your dermatologist provide you with the most accurate and effective advice.

Name *

First

Last

DOB *

Gendre at birth:

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How long have you had acne for? *

Less than 1 year
1 to 2 years
2 to 5 years
5 to 10 years
Mored than 10 years

Which areas of your body are affected by acne: *

Chin
Forehead
Cheeks
Jawline
Chest
Back

How would you describe your skin tone? *

Light
Medium
Dark

acne? have images

Acne causes various skin changes; please select the images that best represent your skin.

Whiteheads
Bkackheads
Papules
Pustules
Nodules
Cysts

How severe is your acne? Please select the category from the images below that describes the acne on your face:

Mild acne: Few acne spots, 1-5 small pimples
Mild to moderate acne: Some acne spots affecting less than half of the face with no cysts or nodules, 6 to 15 pimples
Moderate acne: Many acne spots affecting more than half of the face with some cysts and nodules, 16 to 30 pimples
Severe: Extreme number of spots affecting most of the face with large cysts and nodules, more than 30 pimples with cysts.

How would you describe your skin *

Normal
Oily
Dry
Combination

How much has acne bothered you in daily life? Please select one option from the list below: *

It doesn't bother me
Bothers me occasionally
Bothers me on a daily basis
Has a major impact on my life

Have you had any Topical (prescription grade creams) treatment for acne before? *

Please tick any previous topical treatment you have had before:

Adapalene (Differin)
Treclin
Tretinoin cream
Dalcin
Epiduo
Duac
Zineryt
Personalised creams
Other

Have you had any antibiotics treatment for your acne before: *

Please tick any previous oral antibiotics that you have used in the past:

Lymecycline
Erythromycin
Doxycycline
Oxytetracycline
Trimethoprim
Other

Have you been treated with oral retinoids like Isotretinoin/Roaccutane before? *

When was the last time you had a course of Isotretinoin/Roaccutane? *

Does acne have an impact on the way you see or feel about yourself? *

Please elaborate on how acne does impact the way you see and feel about yourself:

Do you have any medical conditions? *

Please write below any medical conditions that you suffer from:

Are you currently taking any regular medications? *

Please list down any regular medications that you are currently taking:

Do you have any allergies? *

Please list down any allergies that you suffer from: *

Are you currenlty pregnant or trying to conceive:

There are different medications that can be used to treat acne, please select the options that you are willing to try: *

Topical medications ( Personalised Prescription grade creams)
Topical medication and oral medications (This can be a combination of prescription grade creams and pills)
Oral Isotretinoin (Also known as Roaccutane/Accutane)
Spironolactone (For hormonal acne)
unsure / would like to speak to a dermatologist

Write a message to the dermatologist: *

How did you hear about us? *

Consent *

I consent to having this website store my submitted information so they can respond to my inquiry.

ZappedSkin is an Online acne service that provides consultations with UK-based consultant dermatologists through video consultations. ZappedSkin DOESN’T provide in-person face-to-face consultation. ZappedSkin is committed to protecting and respecting your privacy and will only use your personal information to administer your account and to provide the services and products you requested from us. For us to provide you with the best and safest possible service we sometimes have to send you communication via email, text, post, and over the phone. This will include communications from our administration team and healthcare, professionals. In order to provide a safe and efficient service, sometimes ZappedSkin needs to share your information with third parties which include partners that ZappedSkin works with to provide blood tests and pharmacy services. We won't share your information with anyone unless it is part of providing our services to you through one of our third parties partners. To ensure continuity of care, ZappedSkin will regularly send consultation letters to your registered GP. ZappedSkin reserves the right to refuse treatment if patients don't consent for their GPs to receive communications from ZappedSkin.

By checking this box, you agree that you would like to receive more information about our services, products, offers, news, and events *

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.