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Male Patient - Acne Treatment

Page 1 of 2

STEP 1 OF 2

What is your birth sex? *

MALE

FEMALE

Please select which treatment you would like to apply for? *

Who first diagnosed you with acne? *

GP

Dermatologist

Online doctor

If other, please specify:

What treatment are you currently taking for your acne? *

No treatment

Can you tell us more details about your current treatment? (Names of the medications and how long you have been taking them).

Why do you think the medication you are requesting will help your acne? *

Already using it

Have used it in the past

Suggested by a doctor

Suggested by a friend

If other, please specify:

Can you tell us why you think this medication will help you? *

What area of your body is affected? *

Face

Face and Shoulders

Face, Shoulders and Back

Face, Shoulders, Back and Chest

If other, please specify:

Are you currently pregnant, actively trying for a baby or breastfeeding? (Females only) *

Yes

No

Not applicable - I am a man

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