Eczema

Name

Surname

Phone Number

ID Number

Have you used our services before?

Address

City

Postal Code

Have you had eczema before?

What medications/treatments are you currently using for your eczema? (Include dose, concentration or strength)

Where on your body do you have eczema?

Is your eczema well controlled with the treatment?

How often do you experience eczema flare-ups?

Are you pregnant or breastfeeding?

Do you have any other medical conditions?

Are you currently taking any other medication?

Do you have any allergies including allergies to medication?

Please upload a minimum of 2 photos of your eczema areas including a normal area of your skin, to allow our doctors to accurately assess your skin.

I have read and agree to the Terms and Conditions and Privacy Policy (POPI) of the use of this Website and Service. I understand the questions above and have answered honestly. I understand that any inaccurate or false information could potentially be dangerous to my health and safety. The medication that is prescribed is for my personal use only. I understand the side effects and effectiveness of the treatments.I agree to the Terms & Conditions of this platform.I am 18 years or older.I am currently living in Zimbabwe

I Agree to the terms and conditions of this Prescription Application and that of the use of this service.

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