Free Consulation

About You

Let's start with some basic information

* indicates required field

First Name

Last Name

Email Address

Address

Contact Number

Date of Birth

What sex were you assigned at birth?

Female

Male

Prefer not to say

Pregnancy & Breastfeeding

This information is very important for your safety

Are you currently pregnant?

Yes

No

Are you trying to become pregnant?

Yes

No

Are you breastfeeding?

Yes

No

If applicable, are you using reliable contraception?

Yes

No

Not applicable

WARNING: Important Safety Information Tretinoin must not be used during pregnancy.

Your Skin Concerns

Tell us what you'd like to address

What would you like to treat with tretinoin? (Select all that apply)

Acne

Fine lines or wrinkles

Sun damage

Uneven skin tone or pigmentation

Rough texture

Other (please specify)

Please specify:

How long have you had these concerns?

Less than 6 months

6-12 months

Over 1 year

How would you describe the severity of your skin concern?

Mild

Moderate

Severe

Your Skin Type & Sensitivity

Help us understand your skin better

How would you describe your skin?

Very dry

Dry

Combination

Oily

How would you describe your skin tone and how it responds to sun exposure?

The melanin level of your skin affects how it ages.

Very dark

I have dark brown or black skin. I never burn and tan darkly.

Dark

I have brown skin. I very rarely burn and always tan.

Medium

I have olive skin. I rarely burn and tan easily.

Light

I have light to medium skin. I sometimes burn but tan easily.

Very light

I have fair skin. I usually burn and tan minimally.

Pale

I have pale skin. I always burn and never tan.

Do you consider your skin to be sensitive?

Yes

No

Not sure

Do you regularly experience any of the following?

Redness

Burning or stinging

Flaking or peeling

Other (please specify)

None of the above

Please specify:

Have you ever been diagnosed with a skin condition such as:

Eczema

Rosacea

Psoriasis

Other (please specify)

None of the above

Please specify:

Current & Past Skincare Treatments

Your skincare history helps us personalize your treatment

Are you currently using any of the following on your face?

Retinol or retinoids

Benzoyl peroxide

Chemical exfoliants (AHA/BHA)

Other prescription skin treatments

Other (please specify)

None of the above

Please specify:

Have you ever used tretinoin before?

Yes

No

What strength (if known)?

How often did you use it?

Did you tolerate it well?

Have you taken oral isotretinoin (Roaccutane) in the past 12 months?

Yes

No

Medical History & Safety

This helps ensure tretinoin is safe for you

Do you have any allergies, especially to skincare products or medications?

Yes (please describe)

No

Please describe your allergies:

Do you have any ongoing medical conditions?

Yes (please describe)

No

Please describe your medical conditions:

Are you currently taking any prescription medications?

Yes (please list)

No

Please list your medications:

Sun Exposure & Lifestyle

Sun protection is crucial when using tretinoin

How much sun exposure do you get on an average day?

Minimal

Moderate

High

Do you use sunscreen (SPF 30 or higher) most days?

Yes

No

Are you willing to use daily sunscreen while using tretinoin?

Yes

No

Do you use tanning beds or intentionally sunbathe?

Yes

No

Upload Your Photos

Clear photos help our clinicians assess your skin

Please upload clear photos of:

Front of face

📷

Click to upload or drag and drop

JPG, PNG up to 10MB

Left side of face

📷

Click to upload or drag and drop

JPG, PNG up to 10MB

Right side of face

📷

Click to upload or drag and drop

JPG, PNG up to 10MB

Area of concern (if different)

📷

Click to upload or drag and drop (Optional)

JPG, PNG up to 10MB

Final Confirmation

Please review and confirm

I confirm that the information I've provided is accurate and complete.

I understand that a clinician will review my answers and that treatment is not guaranteed.

I consent to treatment with topical tretinoin if deemed appropriate.

✅

Consultation Submitted Successfully!

Thank you for completing your dermatology consultation

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Track your application status and communicate with our dermatologists

What happens next?

1

Review

A dermatologist will review your consultation within 24-48 hours

2

Decision

You'll receive an email notification with the outcome of your assessment

3

Treatment

If approved, access your personalized prescription through your patient portal

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Free Dermatology Consultation

About You

Pregnancy & Breastfeeding

Your Skin Concerns

Your Skin Type & Sensitivity

Current & Past Skincare Treatments

Medical History & Safety

Sun Exposure & Lifestyle

Upload Your Photos

Final Confirmation

Consultation Submitted Successfully!

Create Your Patient Account

What happens next?