INITIAL CONSULT

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Full Name* This field is required.
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What state do you live in?* This field is required.We are not in every state yet... but stay tuned!
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We are almost in your state!Share your e-mail address to stay up-to-date with our rapidly expanding network.
SOUNDS GREAT!Maybe later.
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Last 4 Digits of SSN* This field is required.Required for registration with iPLEDGE program
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Mailing Address* This field is required.
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How does your acne make you feel? My acne sometimes...* This field is required.Check all that apply over the last week
is sore, painful, or stinging
makes me embarrassed or self conscious
interferes with my desire to do things like shopping
influences the clothing I wear
affects my social and leisure activities
prevents me from working or studying
creates problems with my partner, friends, or relatives
takes up a lot of time applying treatments
causes problems with intimacy
none of the above
10
Photo of your US-issued ID showing face and legal name, and that of the parent/guardian if child is under 18:* This field is required.
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Max. file size: 10.6MB
Please upload two photos if minor and adult both possess identification
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Do you have insurance?NOTE: Insurance may help you get your medicine and lab tests (blood tests) more affordably, but insurance can not be used for Vitamin A consult or subscription payments.
YESNO
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How severe is your acne?
Mild- very little acne
Moderate
Severe- scarring or persistent
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How long have you had acne?* This field is required.
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Which of these topical medications have you tried for acne?* This field is required.
None
Retinoid (e.g. Tretinoin, Retin-A, Tazorac, Tazarotene, Differin, Adapalene, Epiduo)
Topical antibiotic (e.g. Clindamycin, Erythromycin, Metronidazole)
Topical Clindamycin
Benzoyl peroxide (e.g. Duac, Benzaclin, Panoxyl)
Dapsone/Aczone
Salicylic acid: ProActiv, Neutrogena, Clean and Clear
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Which of these oral medications have you tried for acne?* This field is required.
None
Doxycycline or Minocycline
Erythromycin
Cephalexin
Tmp-Smx (Bactrim)
Isotretinoin
Birth control pills
Spironolactone
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What is your weight (lbs)?* This field is required.
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Do you have you ever had any of the following medical conditions?* This field is required.
None
Irritable Bowel Syndrome
High cholesterol
Dry eyes or use contacts
Frequent nosebleeds
Pancreatitis
Liver disease
Frequent headaches or pseudotumor cerebri
Depression or anxiety
Suicidal thoughts
Crohn's disease or Ulcerative Colitis (Inflammatory Bowel Disease)
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Other Active or Past Medical Problems* This field is required.
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All Current Medications and Supplements* This field is required.
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Medication Allergies* This field is required.
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Do you have a family history of Crohn's Disease or Ulcerative Colitis (inflammatory bowel disease)?* This field is required.
No
Yes, in a distant family member
Yes, in a close family member (parent, brother, sister, or child)
22
Let's talk about mental health. Which applies to you?
I generally don't have problems with my mental health.
I've had problems with anxiety or depression in the past, but I'm doing well currently.
I continue to suffer with significant anxiety or depression.
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Have you ever taken isotretinoin before?* This field is required.
YESNO
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Which applies to you?We respect all gender identities, however for this question we are required to ask about your birth gender/sex in order to assess reproductive potential as it relates to isotretinoin.
Male
Female with reproductive potential
Female with tubal ligation or tubal sterilization (considered a female of reproductive potential due to isotretinoin regulations)
Female with no reproductive potential due to hysterectomy or surgical removal of ovaries
Female with no reproductive potential due to menopause
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How long ago did you last take isotretinoin?E.g. today, yesterday, 6 months ago, or 10 years ago
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Are you currently on a course of isotretinoin?
YESNO
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Once you have taken isotretinoin, you are given an iPLEDGE number that stays with you for your lifetime. If you know your iPLEDGE number, please input it here.
28
Are you currently pregnant or nursing?
YESNO
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Are you currently sexually active?
Yes, with men only
Yes, with women only
Yes, with men and women
No
30
Are you currently using any form of hormonal contraception?
YESNO
31
How long have you been using hormonal contraception?
32
What is the first type of contraceptive you will use to prevent pregnancy while taking isotretinoin?
Implantable Hormones
Male Vasectomy
Hormonal IUD (LNg 20)
Tubal Sterilization
Non hormonal IUD (Copper T380A)
Hormonal Injectable (single)
Hormonal Transdermal Patch
Hormonal Vaginal Ring
Hormonal Combination Oral Contraceptives
Abstinence
33
What is the second type of contraceptive you will use to prevent pregnancy while taking isotretinoin?
Male Latex Condom
Diaphragm
Cervical Cap
Vaginal Sponge
34
Is your abstinence part of a lifestyle choice (such as a religious practice) or is it a social circumstance (such as not having a current partner)?
I am abstinent because it is a lifestyle choice I have made.
I am abstinent mostly because I do not have a current partner.
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Do you commit to not engaging in sexual activity for 1 month PRIOR TO taking isotretinoin, while you are on isotretinoin and until 1 month AFTER you stop taking isotretinoin?
YESNO
36
Please upload three (3) photos showing the front and both sides of your face. Please also upload a photo of your chest (1) and a photo of your back (1) if you have acne or scarring in these areas.* This field is required.
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Max. file size: 10.6MB
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I certify that I have filled this form honestly, I consent to telemedicine and that I am over 18 years of age, or that this form is being filled on behalf of someone under the age of 18 of whom I am the parent or legal guardian. I agree to the terms, conditions, telemedicine consent, and privacy policy available for review at www.getvitamina.com.* This field is required.Signature of Adult 18+ (should match ID)
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38
Consultation submission* This field is required.
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ORDER SUMMARY
Total costUSD
Initial consultationThis consultation is for your dermatologist to determine whether you are a candidate for isotretionoin (generic accutane) based on the information and photos provided.
$19.00+
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Total cost $0.00
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