What is your date of birth?

Have you used any of the following skin lightening medications or therapies?

HydroquinoneTretinoin (Acretin, Retin-A, Atralin, Avita, Refissa, Renova, Retin-X, Vesanoid)Tazarotene (Tazorac, Avage, Fabior)Adapalene (Differin, Epiduo)Azelaic acid (Skinoren, Azelex, Finacea)Chemical peels (Glycolic acid, Salicylic acid)Laser treatmentNo

Do you have any family history of skin cancer?

If yes, please tell us more (Who? What kind of skin cancer? At what age?)

Where are the dark spots (hyperpigmentation) on your skin that requires treatment?

FaceBackChestStomachArmsLegsOthersNone apply – I do not have dark spots, but I want to lighten my skin tone

Please list the names and reasons for any medications or over-the-counter skin products you are currently using.

Do you suffer from any of the following conditions?

MelasmaPost inflammatory hyperpigmentationSolar lentigo (liver or age spots)Drug-induced hyperpigmentationEczemaPsoriasisFrecklesNone apply

Certain symptoms can be a sign of skin conditions that wouldn't respond to our treatment, and it would be more appropriate to see a doctor in person rather than our service.

Dark spots or lesions that are change in size, shape, or color over timeDark spots that are itching or painfulDark spots are raised, and I can feel them on the skin. They are NOT flat.Dark spots are spread over my whole bodyDark spots are related to a physical or chemical injury to the skinPatches or areas of skin that are lighter than my overall skin toneNone apply

Some medical conditions can make your skin condition too complex for us to manage online and you should see a doctor in person. Select all that apply to you. (check one ore more

PregnantBreastfeedingSkin cancerVitiligoXeroderma pigmentosumNeurofibromatosisHyperthyroidismAddison's diseaseHemochromatosisNone apply

Dark spots can sometimes be caused by certain medicines. Do you take any of the following medicines?

Oral contraceptives (birth control)Hormone replacement therapy (HRT)Amiodarone (Cordarone, Pacerone)Hydroxychloroquine (Plaquenil)Doxycycline (Tetracycline antibiotics)Minocycline (Tetracycline antibiotics)Phenytoin (Dilantin)Chemotherapy agents (cancer medicines)None apply

Do you have any drug allergies?

YesNo

Do you take other medication(s) or have any other medical conditions?

Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids and WHY you are taking them.

YesNo

Anything else you would like us to know?

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details (if available)

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Billing and delivery details

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Delivery Location
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Street Name/No:
Address Details:

Personal Details

Title: Mr.Ms.
First Name: Last Name:
Mobile Number: E-mail:

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After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.