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Patient details

Patient full nameEmailPhone

Date of birth

Enter a date up to 17/10/2026.

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IE · Acne · Full

This form is for ongoing facial or body acne. Please upload a clear, well-lit photo of the affected area — this is required for the doctor to assess severity and choose the right treatment. Severe or scarring acne, or acne that hasn't responded to previous treatment, is usually better managed by a dermatologist and may be redirected to a video consultation or referral rather than treated through this form.

About your acne

Please upload a clear, well-lit photo of the affected area

How long have you had this acne, and where is it (face, back, chest, more than one area)?

What treatments have you already tried for this? (select all that apply)

Nothing yetOver-the-counter products (benzoyl peroxide, salicylic acid, etc.)Prescribed topical treatment (cream/gel)Prescribed oral antibioticPrescribed oral isotretinoin (Roaccutane)Prescribed hormonal treatment (contraceptive pill for acne)

Does the acne leave scarring, dark marks, or pitting once it clears?

How is the acne affecting you day to day?

Your health

Could you be pregnant, are you trying to conceive, or are you breastfeeding?

Are you using, or planning to use, hormonal contraception?

Any known allergy to tetracycline antibiotics (e.g. doxycycline, lymecycline) or to clindamycin?

Do you have lupus (SLE), or any autoimmune condition?

Are you currently taking any vitamin A supplements, or any other retinoid/acne medication not already mentioned?

Do you have irregular or infrequent periods, excess facial/body hair growth, or significant recent weight gain alongside the acne?

Do you have plans for significant sun exposure (e.g. holiday, outdoor work) in the near future?

Patient address

Required for medical documents and any physical materials.

Street addressApt / unit (optional)CityEircode (optional)

Data sharing consent (GDPR)

I confirm the details above are accurate and consent to a video consultation with the selected clinician.I consent to my personal and medical data being processed by Global Health and shared with its treating clinics and medical network — including clinics in other countries — for the purpose of my care, service improvement, and security. Privacy PolicySend me appointment updates via WhatsApp (optional)

Acne Treatment

Acne Treatment

About your acne

Your health