Consultation - Mentor Pharmacy

3 Agreement and Consent

This section confirms that you understand how to use the treatment correctly and safely, and that you give your consent to receive it.

Understanding of Treatment and Risks

I understand that Vaniqa is not a hair removal cream and results take several weeks
I have been informed of possible side effects such as redness burning or acne
I will apply the cream only to affected facial areas and avoid eyes and mouth
I will stop using the treatment if skin becomes irritated or allergic reaction occurs
I will contact a GP if symptoms worsen or do not improve after 4 months

Consent

I confirm that I consent to treatment with Vaniqa via this pharmacy and that the information I have provided is accurate

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for Unwanted Facial Hair

Unwanted Facial Hair

1 About Your Health

What's your gender?

What is your date of birth?

Do you have any of the following medical conditions?

Are you pregnant or trying to become pregnant?

Are you breastfeeding?

Do you take any regular medications including hormonal treatments?

Yes

Do you have any allergies to creams skin products or preservatives?

Yes

2 About Your Condition

Where is the unwanted hair located?

How long have you had this issue?

Have you previously been diagnosed with a condition that causes unwanted hair growth?

Are you currently using any other treatments for hair removal in this area?

Yes

Are you experiencing any of the following?

3 Agreement and Consent

Understanding of Treatment and Risks

Consent

Assessment Progress

Quick Links

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for Unwanted Facial Hair

Unwanted Facial Hair

1 About Your Health

What's your gender?

What is your date of birth?

Do you have any of the following medical conditions?

Are you pregnant or trying to become pregnant?

Are you breastfeeding?

Do you take any regular medications including hormonal treatments?

Yes

Do you have any allergies to creams skin products or preservatives?

Yes

2 About Your Condition

Where is the unwanted hair located?

How long have you had this issue?

Have you previously been diagnosed with a condition that causes unwanted hair growth?

Are you currently using any other treatments for hair removal in this area?

Yes

Are you experiencing any of the following?

3 Agreement and Consent

Understanding of Treatment and Risks

Consent

Assessment Progress

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