Eczema and dermatitis consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Have you been told by your GP or dermatologist (skin specialist) that you have eczema? *

Have you used a steroid cream for your skin rash before? *

How long would you normally use a steroid treatment such as this to see an improvement in your condition? Select one answer *

Less than a week
1-2 weeks
4 or more weeks
I use it continually without a break

What symptoms do you have at the moment? Select one or more answers *

Dry skin
Itching
Redness
Thickened or cracked skin
Bleeding
Blisters
Weeping or crusting
Fever
Other

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

Please can you give some more details about your symptoms? *

Is the area sore? *

How often do you experience itching? Select one answer *

Sometimes
On most days
Every day

Which parts of your body are affected by rash? Select one or more answers *

Hands
Groin
Armpit(s)
Arms
Legs
Chest
Face
Scalp
Other

Please can you tell us where you have your skin condition

Please provide as much detail as possible so that our medical team can ensure that this is a safe and effective treatment for you.

Where is rash *

Have you been diagnosed with Hidradenitis suppurativa by a doctor?

Could you provide more details about your condition to help us determine if this treatment is appropriate for you?

For instance:

Have you been diagnosed with any other condition, such as lichen sclerosis? If so, which one?
Have you used this treatment on this area of your body before? If so, was it effective, and how long did you need to use it?

Please provide more details *

Have you ever had a diagnosis of one of these conditions?

Acne
Rosacea
Perioral dermatitis

Face rash acne *

Have you previously used steroids on your face, experienced initial improvement, but noticed the condition returned soon after discontinuing the treatment? *

Is the rash worsened by any of these? Select one or more answers *

Clothing
Pets
Pollens
Hot or cold weather
Stress
Certain foods
Soaps and detergents
None of these

What are you currently using to treat your skin condition? Select one or more answers *

Nothing
Emollient or moisturiser
Steroid cream or ointment
Other

Please can you tell us what treatment that you are using for your skin condition? Please include how long you have been using this treatment for? *

How often have you been using your emollient or moisturiser? Select one answer *

Several times a day
Once a day
Several times a week
Once a week or less

How often have you been using your steroid cream or ointment? Select one answer *

Every day
A few times a week
A few times a month
Less often than this

Please upload a recent picture of your skin condition.

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

Please ensure it is a recent picture.

File Upload *

Click or drag a file to this area to upload.

What is your biological sex? *

Male
Female

Are you pregnant or breastfeeding? *

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 tell us about your medical conditions *

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

Please provide information about any other medical conditions you have and any medications you are currently taking. Include the medication name, dosage, and how long you’ve been on 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.

Eczema and dermatitis consultation

Do you agree and consent to the following?

Conditions

Treatments

Care and policies