Prescription Skincare Customized Just For You Delivered Right At Your Door
Your best skin awaits. Ready?
First, let's find a dermatologist in your state.
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Enter your date of birth
For medical reasons, we need to your real age to help you with the right formula
Date of Birth
Enter your phone number
Your assigned dermatologist will send you prescription details on this number
What sex were you assigned at birth?
We formulate specific formulas for male & female skin types
Are you currently pregnant, breastfeeding or planning to become pregnant in the next 3 to 6 months?
What skin concern(s) are you seeking therapy for today? Check all that apply
This will help us pick the right ingredients at the right strengths for your skin
Please describe your skin concern(s)
What areas of your body are affected? Check all that apply
Share one or multiple and we will pick active ingredients for your unique needs.
Please describe if other areas of your body are affected
How long have you been experiencing this skin concern(s)?
Have you experienced any of the following symptoms along with your current skin concern(s)? Check all that apply
Please provide additional details on this skin symptom (how long has it been going on, has it been evaluated by a physician and any treatments tried):
Have you used any products/treatments in the past for your skin concern(s)?
Have you used any of the following ingredients/products for your skin concern(s)?
Did you experience side effects with any of these treatments?
Please provide details of any side effects or adverse reactions you experienced using these medications/products. If none please write “none”
Do you have a preferred prescription strength?
Do you have any other diagnosed medical conditions, please include any underlying skin conditions?
Please describe any diagnosed medical conditions and if they are currently well controlled
Do you take any prescribed or over the counter medications or supplements?
Please list all medications and supplements you are taking
Do you have any allergies or intolerances to food, dyes, medications, antibiotics, or anything else.
Please list all allergies
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.
Here’s your first message to your dermatologist. Please introduce yourself and feel free to:
-Ask any questions you have
-List any medical problems you have which were not discussed above
If nothing else to share please click next.
As a reminder, you will not be able to edit your answers after this page
Parental Consent
Phone Number
Gender
Medical History
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.
