Qr8 MediSkin Questionnaire

Please allow 15-20 minutes to complete this form
Full Name*

First NameLast Name
Email*
example@example.com.au
How did you hear about us?*
Please select just one
Because our treatments contain prescription drugs, there are a few things we need you to understand before continuing:
Your doctor needs honest and detailed information about you to accurately diagnose your skin, and prescribe a customised treatment. The information in this form is also required to legally provide you with a prescription.*

I understand
We ONLY use your medical information to diagnose your skin concerns, prescribe treatment and support you during treatment. Your information is stored securely in accordance with HIPAA medical privacy standards and never shared without your consent.*

I understand
Before you can submit this form and book an appointment, you will upload several makeup-free photos. This is so your doctor can identify you at your video consult (a legal requirement), and safely prescribe treatment. If you are using a mobile device, your camera will automatically open when you reach this question, but if not, you might want to switch to a mobile device now.*

I understand
We may ask you to clarify answers, or resubmit photos prior to your appointment. This is for legal reasons, and your safety. If new photos or information are requested, but not submitted before the date/time requested, we will reschedule your appointment, for your safety.*

I understand
To confirm your appointment, a $50 booking reservation fee is payable. This is redeemable on treatment, if prescribed. This fee is non-refundable/non-redeemable if you cancel or reschedule your appointment within 24 hrs of your appointment time, fail to show up/are 5 or more minutes late for your appointment for any reason, choose not to proceed with treatment if prescribed in this appointment, or do not resubmit photos or other information by the requested deadline.*

I understand
Any treatment you are prescribed by your doctor is based on your skin condition at the time of your consult. Skin changes over time for many reasons, so to ensure you are getting the best and safest treatment for your skin, our invoices expire one month after issue.*

I understand

Let's finish your personal profile:
Date of Birth*
If you are less than 18 years of age, a parent/guardian will need to be present for your video appointment
Postal Address (this is where we will send your treatment cream, so please ensure it is correct)*

Street Address

Street Address Line 2

CityState

Post Code
Mobile Phone Number*
We will text appointment and support information to this number

Is there any other information you would like to share with us, or specific questions you would like answered in your video consult?
Please be as specific as possible

You're almost done! We just need some photos.

High quality photos are a non-negotiable safety feature when using an online service. They are used to legally identify you at your video appointment, and for your doctor to safely analyse your skin and prescribe the best treatment for you. It is vital that you follow the instructions below when taking your photos. If not, we will contact you to retake them. Because your safety is our #1 priority, without acceptable photos, your appointment will be rescheduled.
To take photos:

1. Remove makeup or tinted sunscreen (we need to see your skin!)

2. Remove any oil or moisturiser so the light doesn't reflect off these and obscure your skin

3. Secure hair and head coverings away from your face so we can see all your skin

4. Ensure your camera lens is clean

5. Turn your face towards a source of natural daylight, such as a window or doorway, and hold your camera between you and the light source

6. Look at the screen, and check your face is not in shadow. Do not take photos in direct sunlight, directly under a downlight, or at night as this obscures your skin.

7. Some devices will automatically focus on the background when you are close to the camera. To fix this, just hold the camera further away and tap and hold on the centre of the image to ensure the focus is on your face

8. Remove reading glasses before taking the photo

Here are some examples of acceptable/unacceptable images:

Take a look at your photos before you upload them - if you cannot see the skin condition you are seeking treatment for in the photos, neither can we!
FRONT*

Face the camera front-on
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RIGHT PROFILE*

Turn 90 degrees to the left and photograph the right side of your face
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LEFT PROFILE*

Turn 90 degrees to the right and photograph the left side of your face
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Your Skincare Routine

Our dermatology nurse will curate a simple supporting skincare routine for you, as part of your treatment (included in the price). Please upload a photo of your current product lineup (up to 3 photos allowed). We will always try to use the products you already have, before suggesting other inexpensive alternatives that are safe to use with prescription treatments and will help you tolerate your treatment with minimal side effects.
IMAGE 1*

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IMAGE 2

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IMAGE 3

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I confirm that I have understood all questions and answered them truthfully and to the best of my knowledge. I acknowledge that failure to answer truthfully may affect the outcomes of any medications I am prescribed or have unintended side effects.*

YES
Please keep me up to date with Qr8 MediSkin news and the latest information on products and services*

YESNO
Should be Empty: