Drma

Prescription Skincare
Customized Just For You
Delivered Right At Your Door

Your best skin awaits. Ready? 44

First, let's find a dermatologist in your state.

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U.S. Licensed
Dermatologists
HIPAA
Compliant
LegitScript
Certified

Help us determine how sensitive your skin is.How do you typically react to new products?

This will help us pick the right ingredients at the right strengths for your skin

Very sensitive:
I tend to react to new topical products with irritation
Mildly sensitive:
I tend to tolerate most products, if I get irritation it is mild and goes away with time
Not sensitive:
I've never had any issues with irritation to new products

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Please describe your skin concerns in detail

(include any associated symptoms and if you have ever been previously evaluated or given a diagnosis by a physician).

How long have you been experiencing this concern?
List all medications and supplements you are prescribed/taking. If none, please write “none.”

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Have you experienced any adverse reactions from any prior skin products/therapies?

Redness, dryness, irritation or peeling can often occur with retinoid products, let us know if you have experienced this in the past so we can adjust your formula to meet your needs.

Do you have a preferred prescription strength? If not, write no and the doctor will decide.

Do you have any underlying chronic skin conditions or skin issues? (e.g. sun sensitivity, acne, rosacea, psoriasis, sensitive skin, eczema, perioral dermatitis etc.) If none, please write “none.”

Do you have any other chronic medical conditions? If none, please write “none.”

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Here’s your first message to your dermatologist. Please introduce yourself and feel free to:

-Ask any questions you have

-List any medical problem you have which were not discussed above

If nothing else to share please write “none.”

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How long ago was your most recent check up with a physician? We do recommend that our patients have a primary healthcare provider that they see in person on regular basis. If you do not have a primary healthcare provider, you can visit Zocdoc or search federally qualified health centers to find one in your area.

Within past year
Within 2 years
Within 3-5 years
Over 5 years ago

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Review Your Questionnaire

As a reminder, you will not be able to edit your answers after this page

Parental Consent

Yes, I am over 18

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Phone Number

We will use this to let you know if your Dermatologist sends you a message.

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Gender

What is your gender?

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Are you currently nursing or pregnant?

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Medical History

How do you typically react to new products?

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Your Skincare Issues/Concerns

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Your skin concerns in details.

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What allergies or reactions to medication do you have?

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Products you have used in the past.

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Redness, dryness, irritation or peeling can often occur with retinoid products, let us know if you have experienced this in the past so we can adjust your formula to meet your needs.
Do you have a preferred prescription strength? If not, leave blank and the doctor will decide.
Do you have any underlying chronic skin conditions or skin issues? (e.g.: sun sensitivity, acne, rosacea, psoriasis, sensitive skin, eczema, perioral dermatitis etc.) If none, please write “none.”
Do you have any other chronic medical conditions? If none, please write “none.”

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Let us know if there is anything else we should keep in mind before we create your custom formula.

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Let us know if there is anything else we should keep in mind before we create your custom formula.

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How long ago was your most recent check up with a physician?

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Please acknowledge that you understand and agree to the following: I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me. I understand all the questions that have been asked of me. The information that I have provided is accurate and complete. I am the patient who is consenting to be evaluated for treatment and I consent to receiving care via telemedicine.

I acknowledge and agree to the above.