dermatologyintakegeneral - Dickson Chemist

Full name:

NHS/CHI number (if not known use date of birth):

Email address:

Telephone number:

Home address:

GP name and address:

Primary skin concern(s) – please tick all that apply:

If other, please describe the skin concern:

Describe your skin concern in your own words (including duration, severity, and any triggers):

Upload clear photographs of the skin concern (if available):

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Past dermatological history (previous diagnoses, treatments, responses):

Current medications (prescribed, over-the-counter, supplements):

Relevant medical history (tick all that apply):

If other significant condition, please provide details:

Mental health and wellbeing (tick all that apply):

Please provide any additional mental health background you feel is relevant:

How is this skin condition affecting your quality of life?

What are your goals or expectations from this consultation?

Consent for data sharing within the multidisciplinary team (MDT):

I consent to my medical information, images, and investigation results being shared with relevant members of the multidisciplinary team (e.g. dermatologists, pharmacists, nurses, psychologists) involved in my care, where necessary for safe and effective treatment.

Patient declaration and consent:

I confirm that the information provided is accurate to the best of my knowledge.
I understand that my consultation may involve discussion of sensitive health information.
I consent to assessment, investigation, and treatment planning by The Dermatology Clinic.

Patient signature (type full name):

Signature

Clear Signature

Date / Time