Consultation | Mentor Pharmacy

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About Your Health

About Your Condition

The Agreement and Consent

1 About Your Health

This section screens for medical history or medication interactions that could affect treatment suitability.

What is your date of birth?

What is your gender?

Male

Female

Other

Prefer not to say

Do you have any of the following medical conditions?

Liver or kidney disease

Immune system disorders such as HIV or lupus

Skin infections including bacterial viral or fungal

Rosacea or acne affecting the same area

None of the above

Are you pregnant or breastfeeding?

Do you take any regular medications, including immunosuppressants or corticosteroids?

Do you have any known allergies to creams, steroids, or vitamin D analogues?

3 The Agreement and Consent

This confirms the patient understands how to use the treatment, when to seek help, and agrees to be treated under the PGD.

Understanding of Risks and Treatment Use

I understand the purpose of the treatment and what it aims to achieve
I have been informed of possible side effects (e.g., thinning of the skin, irritation, sensitivity to sunlight)
I understand I should not use this treatment on the face, genitals, or broken/infected skin unless advised
I understand the treatment is short-term, and prolonged use can lead to complications
I will contact a GP if the condition does not improve after treatment or worsens

Consent to Treatment

I consent to receive treatment for psoriasis via this pharmacy service and confirm the information I’ve provided is accurate

Yes

1 About Your Health

What is your date of birth?

What is your gender?

Do you have any of the following medical conditions?

Are you pregnant or breastfeeding?

Do you take any regular medications, including immunosuppressants or corticosteroids?

Yes

Do you have any known allergies to creams, steroids, or vitamin D analogues?

Yes

2 About Your Condition

What symptoms are you experiencing?

Have you been diagnosed with psoriasis by a healthcare professional?

How long have you had these symptoms?

Is this a flare-up of a previously diagnosed condition?

Are any of the following present?

3 The Agreement and Consent

Understanding of Risks and Treatment Use

Consent to Treatment

Assessment Progress

Psoriasis Consultation

1 About Your Health

What is your date of birth?

What is your gender?

Do you have any of the following medical conditions?

Are you pregnant or breastfeeding?

Do you take any regular medications, including immunosuppressants or corticosteroids?

Yes

Do you have any known allergies to creams, steroids, or vitamin D analogues?

Yes

2 About Your Condition

What symptoms are you experiencing?

Have you been diagnosed with psoriasis by a healthcare professional?

How long have you had these symptoms?

Is this a flare-up of a previously diagnosed condition?

Are any of the following present?

3 The Agreement and Consent

Understanding of Risks and Treatment Use

Consent to Treatment

Assessment Progress