Female Patients Form 9

FEMALE MALE

No treatment Can you tell us more details about your current treatment? (Names of the medications and how long you have been taking them).

Face Face and Shoulders Face, Shoulders and Back Face, Shoulders, Back and Chest If other, please specify:

Already using it Have used it in the past Suggested by a doctor Suggested by a friend If other, please specify:

GP Dermatologist Online doctor If other, please specify:

YES NO Not applicable - I am a man

NO If YES, please specify:

NO If YES, please specify:

NO If YES, please specify:

NO If YES, please specify:

You have high cholesterol A parent, brother or sister developed heart disease before they were 60 You smoke more than 10 cigarettes a day or use nicotine replacement therapies You are diabetic None of the above If other, please specify:

Yes I confirm this treatment is for my personal use only.

I am happy to continue with my request

I understand and have answered honestly and truthfully