Acne Clinical Trial FormPlease complete the below form to register your interest. Name * First Name Last Name Email * Date of Birth * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about us? * Word of mouth Google Instagram Facebook Other If other, please detail. How long have you suffered acne for? * What sites are involved? * Face Trunk Face & Trunk If you are female, does your acne flare around your menstrual cycle? If you are female, do you have regular periods? Yes No If you are female, are you currently taking Oral Contraceptive pill or have Implanon, Copper Rod or Mirena? Have you been prescribed oral antibiotics for your acne? * Yes No If yes, which antibiotic, what dose and for how long did you take it? What skincare are you currently using? * Please list brand names eg. La Roche Posay Toleraine Cleanser & Cicaplast Baume Have you been prescribed topical creams for your acne? * Yes No If yes, which cream/s, and for how long did you try it? Did these creams cause irritation/redness/peeling, and if so, was it mild/moderate/severe? Do you have sensitive skin that is easily irritated by skincare? * Yes No If yes, why? Have you previously been prescribed Isotretinoin (Accutane, Roaccutane, Oratane)? * Yes No If yes, how long did you take it for? What dose did you take? Did you ‘complete a course’? How soon after you finished did your acne return? Did you experience any side effects? Do you take any regular medications or supplements? Do you have any medicine/drug allergies? Is there anything else you would like to share with us? Thank you! A member of our team will be in touch soon.
