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Prescription Products – Sign Up

A Virtual Consultation Service for providing Personalised Prescription Skincare

Before we can provide you with our prescription only skincare products, we need to verify your suitability for treatment. This is done through our Virtual Consultation Service.

Please complete the following medical questionnaire.

A member of our Clinical team will review your answers and provide you with the most suitable personalised prescription skincare and advice.

If you have previously completed this form and already have an account with us, please click here to log in.

First Name

Last Name

Email Address

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Postcode

Country

Date of Birth

Please create a password for your account:

With regards to your skin condition, which of the following concerns do you have:

Acne

Acne Scarring

Rosacea

Hyperpigmentation/Discolouration

Melasma

Uneven skin texture and/or tone

Fine lines and wrinkles

Enlarged pores

Delving deeper, in relation to your skin condition, which of the following concerns do you have:

Dry Skin

Oily Skin

Sensitive Skin

Ageing Skin

Sun Damaged Skin

Dark under eye circles

Areas of redness

What are your long term goals in relation to treating your skin?

Which of our Prescription Skincare products are you interested in?

Tretinoin

Hydroquinone

Pore Therapy

Which best describes your skin type?

Normal

Dry

Oily

Combination

Sensitive

Are you currently/or have you ever used Accutane (Roaccutane)?

Yes

No

Are you currently using any Prescription Skincare Products?

Yes

No

Are you currently using any over the counter Retinols / Glycolic Acids / Medical Grade Non-Prescription Skincare?

Yes

No

Please provide further information in relation to your current Skincare Regime:

Have you received any form of professional chemical peel treatment within the last 12 weeks?

Yes

No

Do you actively use sunbeds or are you taking a holiday in the sun within the next 4 weeks?

Yes

No

Do you have any allergies that you are aware of?

Yes

No

Do you have any medical conditions, aside from your skin concerns, that you are currently receiving treatment for?

Yes

No

Are you currently taking any medication?

Yes

No

I confirm that I have answered all questions truthfully to the best of my knowledge. I understand that the information I have supplied will form the basis on which a Prescription may be issued. I understand that any purchase I make, herewith, is subject to review by a member of the Aeternum Aesthetics Medical Team and that I may be contacted to provide further clarification where necessary.

I accept

I do not accept

Your journey starts with a conversation.

Book a consultation today and discover what’s possible with the right approach, the right expertise, and the right clinic.

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Aeternum Aesthetics is a skincare and aesthetic clinic in Ashby de la Zouch.

40 Market Street, Ashby de la Zouch, Leicestershire, LE65 1AN

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Aeternum Aesthetics is a medically led, CQC-registered clinic based in Ashby-de-la-Zouch.