Acne Scarring Enquiry

First Name *

Last Name *

Email Address *

Mobile Number *

Postcode *

Date of Birth *

GenderFemaleMaleOther

Please enter your gender *

Medical History

Do you have any active or past medical conditions? *

YesNo

Please detail your medical history *

Medications

Do you take any regular prescription medications? *

YesNo

Please list your medications *

Allergies

Do you have any allergies? *

YesNo

Please list your allergies *

About your skin

Please tell us which one of the categories you fall into *

Fitzpatrick Type 1
Fitzpatrick Type 2
Fitzpatrick Type 3
Fitzpatrick Type 4
Fitzpatrick Type 5
Fitzpatrick Type 6

Please tell us which one of the categories you fall into *

Fitzpatrick Type 1
Fitzpatrick Type 2
Fitzpatrick Type 3
Fitzpatrick Type 4
Fitzpatrick Type 5
Fitzpatrick Type 6

How would you describe your skin type? *

NormalOilyDryCombination

Do you still suffer from acne? *

YesNo

Please outline your current skincare routine *

Have you ever had a keloid scar? *

YesNo

Has anyone in your family ever had a keloid scar? *

YesNo

About your acne scarring

How would you grade the severity of your acne scarring? *MildModerateSevere

Acne scarring can be classified into different types depending on the appearance.  Please read the following page before answering the next question https://dermatology.melbourne/services/acne-scarring/

What is the predominant type of acne scarring you have? *Rolling and atrophicBoxcarIce-pickKeloidalPersistent rednessPersistent browness

Time to take photos of your skin & scarring

 

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That's all we need from you at this stage.  Hit Submit and we will get back to you as soon as possible regarding your enquiry.

I confirm that all the information I have provided is true and accurate  *

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