Rosacea prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Can you please confirm your birth gender? *

2. Please share with us the current skin issues you are experiencing. Tick all those that apply to you. *

4. Historically, have you used any treatments for rosacea/acne? *

5. Please share if you are currently taking any prescription or over-the-counter medications, or are currently using recreational drugs? *

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