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Acne Virtual Consult Questionnaire

Acne Virtual Consult Questionnaire

Algorithms by Dr Davin Lim

Thank you for your inquiry. This form is designed for me to understand more about your acne & how to best treat them. It allows my team & I to triage your appointments & provide you with a report.

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HOW THIS WORKS

Step 1. Questionnaire.

Step 2. Good quality photos.

Step 3. Send email to Cutis Dermatology.

Step 4. Processing fee of AUD $490.00 – includes detailed report & virtual consultation.

Step 5. Report generated.

A report will be generated within 7 working days & a consultations will be scheduled shortly thereafter.

YOUR DETAILS

Name(Required)

Hi there,

Just a few key points to get the most out of this virtual consultation-

• This virtual consultation is designed to provide you with a strategic management plan to treat your acne. I do not prescribe any medications during this process (as this re- quires follow ups & in most cases investigations).

• The report will include suggestions for your acne management, including product use (where applicable) as well as higher level treatment options, if indicated.

• The accuracy of this report is based upon the history, as well as good quality photos.

• Acne scar revision strategies will not be discussed in this report as it requires a totally different approach, once your acne has been treated & in remission.

LET’S START!

At what age did your acne start?(Required)
Do you have a family history of acne?(Required)
Do you have a family history of acne?(Required)
How do you personally rate your acne?(Required)
Do you pick your acne spots?(Required)
Do you have any acne scarring?(Required)
Do acne spots leave marks on your skin that last longer than three months?(Required)
Do you get sensitive skin?(Required)
What typically flares up your acne?(Required)
How do you rate your diet?(Required)
Do you consume any dairy products on a regular basis?(Required)
Have you seen a clinician for acne treatment before?(Required)
What treatments have you tried for your acne (pick as many as applicable)?(Required)
What treatments are you open to (pick as many as you are comfortable with)?(Required)

FEMALES ONLY

Are your menstrual cycles regular?
Are you currently on the oral contraceptive pill?
Have you had a diagnosis of PCOS by a medical professional?
Are you planning pregnancy in the next 12 months

HOW TO TAKE PHOTOS

The better the photos the more accurate the assessment. Please follow the guide outlined below. No make-up obviously. I require-

• Full face: 1

• Side (right & left): 2

• Oblique (right & left): 2

Minimum total: 5 photos. Additional close ups will be great. High resolution photos will allow me to zoom in.

In summary 5 plus high-quality focused photographs are required.

Take 5 photos in total. 1 front on, 2 on the right side. 2 on the left side. You can take additional photos of areas such as the temples, nose etc. should there be any scars visible.

Drop files here or
Accepted file types: jpg, jpeg, png, pdf, heic, Max. file size: 50 MB, Max. files: 20.

    REPORT

    A detailed report will be sent to you based on your photos & questionnaire. The accuracy of this report ranges between 80% to 98% accuracy, depending on your information & photos. I will discuss in detail the body of this report during the virtual consultation.

    The body of this report gives one algorithmic approach, based upon your answers & photo- graphs. In some cases, there are several algorithms that can be undertaken.

    *Some cases of acne are hard to diagnose on static photography & rely on a real time examination, deep acne cysts are one example.

    PAYMENT DETAILS

    Option 1) Direct Deposit

    1) Direct Deposit - Please send screen shot if option 1.

    Account Name: Cutis Clinic

    Bank: NAB

    BSB: 084-801

    Account number: 984-160-823

    Reference: PATIENT FULL NAME

    Max. file size: 50 MB.
    Deposit Screenshot

    Option 2) Credit Card (Please note we do not accept AMEX)

    Visa / Mastercard

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