Have you previously been diagnosed with mild to moderate acne by a medical doctor?

Are you pregnant, planning on becoming pregnant, or breastfeeding?

• This treatment is not suitable for use in pregnancy. Treatment should be discontinued for at least one cycle prior to pregnancy.

Are you allergic to any of the following?

• Adapalene
• Benzoyl peroxide
• Propylene Glycol

Do you currently have sunburn?

Do you understand that usage during pregnancy can cause birth defects and you must use effective contraception if there is a possibility you may become pregnant?

• It is essential that you do not become pregnant while using this treatment. You must use effective contraception and stop using your treatment immediately if you forget to use your contraception. If you think there is a possibility of pregnancy, discontinue treatment and speak to your doctor immediately.

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Do you understand that it can take 4-8 weeks of treatment before beneficial effects are seen?

Do you understand if your acne gets worse or starts to cause scarring, you must see your GP?

Do you understand that this medication can make your skin more sensitive to sunlight (photosensitivity)? You should avoid sunlight and sunlamps while using this gel and take care to use sunscreen and cover in protective clothing if sunlight exposure is necessary.

Do you understand that treatment should not exceed 12 weeks?

Do you understand that you should use your treatment once a day, after washing your face with a mild cleanser and fully drying?

Do you understand that this medicine must not come in contact with eyes, mouth, mucus membranes, or eczematous/ broken/ sunburned skin, and that if it does by accident you should seek medical advice?

Do you understand that most people will experience some skin redness and peeling during the first few weeks of treatment? If your skin becomes irritated, you may need to use an oil-free moisturiser, use your treatment less often, or stop using it for a short period to allow your skin to recover and then re-start treatment. If irritation persists or symptoms are severe, stop using the medication and contact our help desk or your GP.

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.