Accutane Follow-up Visit
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Today's date
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Day
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Date
Is this a stand-alone eVisit or part of a Telehealth appointment that you already scheduled?
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eVisit only (asynchronous)
Part of a Telehealth appointment I scheduled
Please provide the date and time of your Telehealth appointment
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Month
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Day
Year
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Hour Minutes
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AM/PM Option
Last 4 digits of credit card used:
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Please provide a photo ID of the patient or legal guardian if the patient is under 18.
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Signature of the patient or legal guardian if the patient is under 18.
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Patient's Name
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Prefix
First Name
Middle Name
Last Name
Suffix
Date of Birth
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/
Month
/
Day
Year
Date
Gender assigned at birth:
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Female
Male
Prefer not to answer
Other
The required iPledge program for Accutane (isotretinoin) has different guidelines for different patient categories. Please confirm which category you are in:
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I am NOT biologically able to get pregnant
I AM biologically able to get pregnant
Name of Person Filling Form if different from Patient
Prefix
First Name
Middle Name
Last Name
Suffix
Email
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example@example.com
Mobile Phone Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
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Postal / Zip Code
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Height (inches):
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Weight (pounds)
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Select all areas currently affected:
Head and face
Neck
Chest
Back
Shoulders
Arms
Abdomen
Groin
Buttocks
Legs
Other
Please describe how severe your acne is currently:
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Mild
Moderate
Severe
Other
Select all descriptions that apply to your acne:
Whiteheads/ blackheads ("comedones")
Red pimples ("papules")
Pus-filled pimples ("pustules")
Deep nodules/ cysts
Red patches
Large visible blood vessels
Painful
Scars
Other
Additional comments/explanations to the questions above:
Please list all the treatments that you are CURRENTLY using for your acne. Include prescriptions and over-the-counter treatments. Which brand name of Accutane/isotretinoin are you taking? What dose? How many times a day do you take it?
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Please select which option best describes your current treatment:
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I am very happy with my current treatment and would like to continue it.
I am somewhat happy with my current treatment, but would like to enhance/adjust it.
I am not happy with my current treatment (due to ineffectiveness or side-effects) and would like to change it.
Other
Please select which option best describes how consistently you use your current treatment:
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I am very consistent, rarely missing a treatment.
I am somewhat consistent, but miss 1-2 treatments per week.
I am not consistent, and miss several treatments each week.
Other
Additional comments?
Are you having any of the following effects (select all that apply)?
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Mild/ tolerable lip, eyes, nose, or skin dryness
Severe dryness/ cracking/ rash of lips, eyes, nose, or skin
Nosebleeds
Headaches or dizziness
Nausea, vomiting, diarrhea, or any other stomach or bowel symptoms
Changes in vision
Changes in moods
Depression
Changes in sleep or eating habits
Losing pleasure in activities usually enjoyed
Joint aches or muscle pain
Hair loss
Sun sensitivity
No side-effects
Other
Please describe any side-effects you selected above, and any other side-effects you may be experiencing:
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To continue taking Accutane/ Absorica (isotretinoin), you must confirm iPledge participation by checking each of these top 3 requirements:
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I will follow all iPLEDGE requirements, including abstinence/contraception (for patients who can get pregnant).
I will not share pills with anyone.
I will not donate blood while taking the medication.
I do NOT want to continue Accutane/ Absorica (isotretinoin).
Regarding pregnancy prevention requirements, I am:
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Completely abstinent
Using 2 forms of contraception
My 2 forms of contraception are:
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Are you currently taking any other oral medication(s) besides Accutane for this condition?
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No
Yes
What is the name and dose? How many times a day do you take it?
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Are you having any of the following side-effects (select all that apply)?
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Headaches or dizziness
Nausea, vomiting, diarrhea, or any other stomach or bowel symptoms
Sun sensitivity
Fatigue
Yeast infections
No side-effects
Other
Please describe any side-effects you selected above, and any other side-effects you may be experiencing:
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Please describe any other clarifications, side-effects or issues about your current treatment, if any:
Please update Access Dermatology on all active Medications you use (other than those for your skin condition listed above), including prescriptions, over-the-counter, vitamins, supplements.
Please update us on your Allergies:
Please provide clear in-focus photos (1-5) of your condition. You may also include any relevant labwork or other documents (ideally as scanned/downloaded PDFs).
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Any other comments/clarifications:
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After Submitting This Form:
You will be directed to our Spruce Health portal sign-up. If you have not yet signed up for our Spruce Health portal, please do so (may use as mobile app or desktop version). We recommend you download the mobile version and turn notifications "On" so you will be notified when we send messages and your consultation report (for eVisits). We will also initiate Telehealth visits (if scheduled) in this portal. If you do not hear from us as per our current turnaround time, please message us via Spruce or reply to the confirmation email that you will receive. Thank you for allowing us to assist you on your skin wellness journey!
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This field is for administrative use only.
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Name
Prefix
First Name
Middle Name
Last Name
Suffix
DOB
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Month
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Day
Year
Date
Visit Type:
eVisit, asynchronous, technology-based, code G2010
Telehealth, synchronous audio/visual, code 99202 (modifier 95)
Telehealth, synchronous audio/visual, code 99203 (modifier 95)
Telehealth, synchronous audio/visual, code 99212 (modifier 95)
Telehealth, synchronous audio/visual, code 99213 (modifier 95)
Impression:
Acne (L70.0)
Rosacea (L71.9)
Folliculitis (L73.9)
Hidradenitis (L73.2)
Severe
Nodulocystic
Scarring
Improving
Not improving
Worsening
Controlled
Not controlled
Other
Plan:
Your prescriptions were sent to (please call your local pharmacy before picking up; specialty pharmacies contact you within 1 day, but you may call them anytime after receiving your report):
Your local pharmacy
A specialty pharmacy: CLRx (940) 312-5943
A specialty pharmacy: Clear Cities (201) 716-2568
A specialty pharmacy: SIP pharmacy (201) 222-5452
A specialty pharmacy: ZCP-Central (929) 397-0331
A specialty pharmacy: Stines
(No prescriptions were sent)
Other
Instructions attached:
Using Retinoid Topicals
Schedule a phone call for clarification
Diet and Life-Style Guidelines
Dry Skin Care
Sun Protection
Other
Recommended follow-up visit:
in 2 weeks.
in 4 weeks.
in 4 weeks if there is no improvement; in 3 months if there is improvement.
in 3 months, unless new symptoms, side-effects, or worsening occurs.
in 6 months, unless new symptoms, side-effects, or worsening occurs.
in 1 year, unless new symptoms, side-effects, or worsening occurs.
In-person visit, at Integrated Dermatology of NJ, 385 Route 18, Suite E, East Brunswick, NJ 08816. If you don't hear from them, please call them at (732)-390-1883 and state that Dr. Shraga referred you for an expedited appointment.
In-person visit, you will make arrangements as per your preference.
As soon as possible.
Other
Alexander Shraga, MD
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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