What are your biggest skin concerns?
Select all that apply
What’s your age?
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What products have you tried in the past or do you currently use?
DRMA Helps Rebuild Collagen and Gets You Results You Can See, FAST
Your DRMA cream contains FDA-approved, prescription-strength ingredients customized just for your skin. Everything works at the cellular level to rebuild collagen, tighten your skin, and give you a more youthful appearance
How would you describe your current skincare routine?
Your Skin Deserves Better!
Most women don’t realize their skin is always changing and needs support at a deeper level. DRMA contains clinical doses of active skincare ingredients – the type you will never find in department stores or drugstores.
Ok let’s connect you to a licensed dermatologist.
Which state do you reside in?
Congrats! You qualify for a DRMA Virtual Consultation.
Please create an account so your doctor can communicate with you easily:
Enter your phone number
Your dermatologist will send prescription details to 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 areas of the body are most affected?
Check all that apply
How long have you had these concerns?
Have you experienced any of the following symptoms alongside your skin concerns?
Have you used any of the following for your skin concerns?
Please share any side effects you experienced with any of these products. If no side effects, indicate “None”
Do you have a preferred prescription strength?
Do you have any diagnosed medical conditions?
Please describe your medical conditions and timeline
Do you take any prescribed medications or over the counter supplements?
we need to consider any drug interactions even with topical medication
Please list all medications you are taking
Do you have any known allergies or intolerances to any foods, dyes, medications, antibiotics, or anything else?
Please share allergies and intolerances
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.
Nice Work! Your DRMA Intake is Complete
Send your first message to your dermatologist! Please ask any questions you have or share more details they should know that weren’t already covered.
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.
We already have your email in our system. No need to fill out the questions again — you can go straight to placing your order.
