Rosacea consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Do you have rosacea? *

Yes
No
Not sure

We’re sorry, but there are no suitable treatments for you.

The safety and well-being of our patients is our number one priority, and based on your answers, we can’t recommend any of our treatment options. We know this is both frustrating and disappointing, but we want to make sure that we’re putting your health first and that you find the right care.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Does your rash look like this photo?

Rosacea rash *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

How long have you been experiencing rosacea? Select one answer *

Just started
1-3 months
3-6 months
6-12 months
Longer than 12 months

Please select the symptoms that you experience: Select one or more answers *

Flushing
Persistent redness
Visible blood vessels
Papules (small red bumps)
Pustules (pus-filled swellings)
Thickened skin
Other

Please can you provide more details about the symptoms that you experience: *

Does the rosacea only affect your face? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you currently experiencing any other skin conditions? *

Please can you tell us what other skin conditions you are currently experiencing? Select one or more answers *

Eczema
Acne
Psoriasis
Seborrheic dermatitis
Lupus
Other

Please tell us about the other skin condition you are currently experiencing *

Do you currently experience any of the following symptoms:

Eye pain
Sensitivity to light (photophobia)
Deterioration in your vision

Rosacea eye CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you been diagnosed with any of the following:

Problems with your heart or circulation
Liver disease including porphyria
Any autoimmune diseases
Any conditions affecting your gut (including surgery)
Blood disorders
Low blood pressure including postural hypotension
Myasthenia gravis

Red flags rosacea *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Please upload a picture of your rosacea.

A picture will help our healthcare team to make an appropriate decision about your treatment.

File Upload *

Click or drag a file to this area to upload.

Are you currently using a treatment for your rosacea? *

Please can you tell us what you are currently using: Select one or more answers *

Metrogel or Rozex
Soolantra
Mirvaso
Finacea
Tetracycline (e.g doxycycline)
Erythromycin
Other

Can you tell us more about your treatment plan for these medications?

Are you intending to use this/these treatment(s) you have ordered with or instead of the treatment you are currently using?
If you are using it alongside who has advised you to use these treatments together?

Rosacea treatment plans *

Have you used any treatments for Rosacea in the past? *

Please can you tell us what treatments you have used before to treat your rosacea? Select one or more answers *

Metrogel or Rozex
Soolantra
Mirvaso
Finacea
Tetracycline (e.g doxycycline)
Erythromycin
Other

Please can you provide more detail about the treatments that you have used before, how effective they were and did you experience any adverse effects: *

Do you take any of the following medicines:

Statins
Blood thinners (such as warfarin)
Oral antibiotics
Medications for depression
Oral isotretinoin
Antipsychotics
Antidepressants
Erogtamine or dihydroergotamine
Medications for Parkinsons disease
Tolterodine or Domperidone

Other meds CI *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

What is your biological sex? *

Male
Female

Are you pregnant, breastfeeding, or trying for a baby? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any other medical conditions not already mentioned? *

Please provide more details *

Are you taking any other medications that have not already mentioned? *

Please share details of any other medical conditions you have and any medications you are currently taking. Be sure to include the name of each medication, the dosage, and how long you’ve been using it.

Other medication *

Do you have any other allergies that you have not previously mentioned? *

Please give us more details on these allergies *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about your own healthcare
I shall be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me and are truthful.
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
If prescribed a treatment, I will read the Patient Information Leaflet (PIL) that will be provided.
If prescribed a treatment, I will inform my GP of my treatment and contact them if I have any side effects associated with the treatment.
You agree to our terms and conditions, privacy policy and acceptable use policy
You are aware you will be subject to a soft check to validate your identity using LexisNexis.

Checkboxes *

I agree to the statements and give my consent for any treatment provided.

Are you registered with a GP in the UK? *

(Optional) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Summary care records

I consent

(Optional) Do you give us consent to write to your GP to share information of this supply and any information we hold about you?

Send information to GP

I consent

Product Category

Important

We review all orders to ensure they’re the best treatment we can offer you. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide what you ordered is unsafe for you, given the other information you provided, we won’t issue any treatment. However, we may call you and suggest alternatives.

Rosacea consultation

Do you agree and consent to the following?

Conditions

Treatments

Care and policies