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Virtual Consult Questionnaire

Virtual Consult Questionnaire

By Dr Davin Lim

Thank you for your inquiry. Please fill out the form below so we can understand more about your skin concerns and goals.


Next Steps: Install the Survey Add-On

This form requires the Gravity Forms Survey Add-On. Important: Delete this tip before you publish the form.


What is your primary concern?(Required)

* Acne consultations: The aim of this consultation is to provide you with a strategic management plan for your skin. I do not prescribe medication for acne as my work is entirely procedural. Medications such as the oral contraceptive pill, anti-hormonal medications & isotretinoin all require close monitoring. A medical dermatologist can assist in prescriptive medicine.
How long have you had this problem?(Required)
Have you had treatment for this problem before?(Required)
Are you currently using any topicals or oral medication on your skin (gels, creams, serums, lotions, tablets, herbs etc...)?(Required)


Photos are crucial to ascertain a diagnosis. The clearer the better. Please provide a series of between 5 to 8 photos in good lighting.

Here is a super quick 2 minute video that shows you how to take clinically sound photos.

Many thanks for taking the time to complete this questionnaire. The more information you can provide the better I can understand how to formulate a treatment plan for you.

For record keeping purposes, you may record the consultation from your end. This may assist you in recalling the points discussed. Additionally I will provide you with written recommen- dations during the consultation. This will be sent to you in real time.

Disclaimer: a virtual consultation is a compromise that bridges the gap between no consul- tation & a real time consultation. The accuracy of a diagnosis depends largely upon photo- graphs, however some aspects of skin are difficult to capture on static photographs. Examples include shadowing of contours, reflectance of light, ability to visualize redness, & 3D spatial concerns. Dr Davin Lim.

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


    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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