Mon - Fri: 9:00 - 17:00
01493 600610

NHS
Private
Vaccine
Travel
Ear
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NHS
Private
Vaccine
Travel
Ear
Shop

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Eczema consultation

Eczema-Consulation

Patient details

Please complete the consultation as accurately as possible.

Are you completing the consultation for yourself?

Yes

Who are you ordering for? Please give details

First Name

Last Name

Date of birth

Phone number

Address

City

Postcode

Is the shipping address the same as above?

Yes

What is your shipping address?

Skin condition

Please complete the consultation as accurately as possible.

Just like a traditional consultation we're going to ask you about your medical history and symptoms. Your answers will help us assess your suitability for treatment. Please answer all questions to the best of your knowledge and in full. If you have any problems understanding or answering a question please call on 01493600610.

I understand

Have you been diagnosed with eczema by a GP or dermatologist?

Yes

Not Sure

When did the symptoms started?

Which of the following symptoms are you currently experiencing?

Itchy Skin

Dry Skin

Red or inflamed patches

Thickened or cracked skin

Weeping, oozing or crusting

Bleeding

Vesicles or blisters

Fever

Other symptoms

Please give more details

Which parts of your body are affected by eczema?

Hands

Arms

Legs

Chest

Face

Scalp

Other

Please give more details

Do you suffer from asthma or hay fever?

Yes

Please give more details

Is there any family history of Eczema/Asthma/Hay fever?

Yes

Is your eczema worsened by any of these?

Clothing

Pets

Pollens

Hot or cold weather

Stress

Certain foods

Cosmetics & toiletries

Hair dye, Acrylic nail, other beauty products

New paint in the house

Hand wash/ hand sanitiser

Anything related to your work or your hobby

None of the above

Other than your skin condition are you experiencing any of the following?

Fever, high temperature or uncontrollable shaking

Feeling generally unwell

Persistent runny, watery discharge from your nose

Any area of skin showing pus/crust/discharge/open wound

None of the above

What treatments are you currently using for eczema? (Tick all that apply)

Emollients or moisturisers

Steroid creams or ointments

I'm not using anything for my eczema

Other

Please tell us exactly what you're using for your eczema and how long you've been using it for.

Other than those already mentioned, do you have any other significant medical conditions, illnesses, hospital stays or past surgical procedures?

Yes

Please provide details

Are you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?

Yes

Please provide details

Do you have any known allergies?

Yes

Please provide details

Are you currently pregnant or breastfeeding?

Yes

Please provide details

Consent

I understand the questions asked, have answered them honestly, and that this treatment is for myself only. I understand the side-effects, other treatment options available.

I consent to the Online Chemist accessing my NHS summary care record (SCR) to process my treatment, if needed

I consent to have Online Chemist store my submitted information so they can respond to my inquiry.

Photo upload

Please upload at least 2 photos of affected areas - one close-up and the other from distance.

Caution:
Please do not upload photos of private parts.

Image Upload

Upload image

Official use only

Experiences Shared by Our Customers

Don’t simply rely on our claims, become part of the delighted community of thousands of customers who are experiencing the remarkable benefits!

Online Chemist in Gorleston, an NHS online pharmacy and travel vaccine clinic

Online Chemist
82 Middleton Road
Gorleston
Great Yarmouth
Norfolk, NR31 7AH
Phone: 01493 600610
Email: info@onlinechemistuk.net

Superintendent Pharmacist:
Obaidullah Zaman
BPharm, MPharm, PGDip (Pharmacy), MRPharmS, IP
GPhC Reg. Number: 2083409

Pharmacy Premises GPhC Reg. Number: 9011159

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NHS online pharmacy Gorleston Great Yarmouth Norfolk

OPENING HOURS

Monday 09:00 – 17:00
Tuesday 09:00 – 17:00
Wednesday 09:00 – 17:00
Thursday 09:00 – 17:00
Friday 09:00 – 17:00
Saturday Closed
Sunday Closed

Click here for driving directions

Online Chemist is a trading name of Nomaz Limited.
Registered in England – 11349276.

Eczema consultation

Patient details

Skin condition

Photo upload

Caution:Please do not upload photos of private parts.

Experiences Shared by Our Customers

OPENING HOURS

Caution:
Please do not upload photos of private parts.