Top Health Center

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Date of Birth *

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Address *

Sex *
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Upload Past Medical Records *

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One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

1 - At what age did your acne begin? *

2 - What areas of the skin are affected?*

3 - Do other family members have acne? *

4 - What things or situations make your acne better? *

5 - What things or situations make your acne worse?*

6 - Have you tried any of these over-the-counter medications?*

7 - Have you tried any of these topical medications?*

8 - What oral medications (pills) have you tried?*

9 - If you've taken medications in the past, were they effective?*

10 - Have you experienced any side effects with medications?*

11 - Do any of these apply to you?*

12 - If you are taking birth control, please list the medication and how long you have been taking it. *

13 - Do you take any medicines, vitamins, or supplements?

14 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

15 - Please list any allergies you have.

16 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

17 - Do you have a preferred treatment?*

18 - Do you have a preferred dose or strength?

19 - Do you have a preference on how often you'd like your medication?*

20 - Please enter preferred pharmacy information.*

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