Skin Care - Acne Questionnaire - Peaks Curative

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Patient Name *

First

Middle

Last

What was your sex assigned at birth? *

Male
Female

Date of Birth *

Shipping Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

I am capable of making sound medical decisions *

Yes
No

Do you have an allergy to a particular medication? *

Yes, I have a history of drug allergies
No known drug allergies

List all the medicines you are allergic to. *

Have you used any acne treatments in the past? *

Yes
No

What were they, and how did they affect your skin? *

Do you have any history of skin conditions (e.g., eczema, psoriasis)? *

Yes
No

What skin conditions do you or have you had? *

Are you currently taking any acne medication or supplements? *

Yes
No

What acne medications or supplements are you taking? *

How long have you been experiencing acne? *

1 - 3 months
3 - 6 months
6 - 12 months
1 year or longer

What type of acne do you have? *

Whiteheads
Blackheads
Cystic
Other

Are you currently using any of the following medications: *

Azelaic Acid
Clindamycin
Tretinoin
Niacinamide
Hydroquinone
Other
None

Patient Assertation *

I attest that I am the patient identified at the top of this form and that I am completing this questionnaire truthfully and of my own free will for my personal medical care. I understand that the information I provide will be reviewed by a licensed healthcare provider for the purpose of determining whether a prescription is appropriate.

Medication Disclosure Clause

I hereby agree to indemnify and hold harmless the reviewing prescriber and/or employees of the prescriber harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication of any other vital medical information.

Prescription will be fulfilled by RxCompoundStore.com. *

Yes, I agree

Additional Concerns or Questions:

Disclaimer: The information provided regarding Peaks Curative compound offerings are for compounded formulations and are NOT an FDA-approved drug label. The suggested formulations are provided for reference only and are based on formulations that have historically been ordered by duly licensed professionals. Compounded products are exempt from FDA approval and no claims are made to the safety and efficacy of any compounded product for any indication or specific use.

Prescribing of the compounds must be based upon the professional judgment of the licensed health care provider after considering the patient’s unique medical condition and factors including body weight, size and overall health status. No liability attaches in any way to any actual or alleged injury to any person or any damage to any tangible property if the compounded product is used beyond the scope as prescribed by your physician.

The licensed pharmacist and/or licensed physician maintains the responsibility to ensure compliance with Section 503A of the Food, Drug and Cosmetic Act, including the requirement that a compound be dispensed pursuant to a valid prescription, from a licensed prescriber, for an identified individual patient. The licensed pharmacist and/or licensed physician is also responsible for ensuring that none of the ingredients appear on an exclusion list maintained by the FDA, and that all the ingredients may be lawfully used in pharmacy compounding.

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