Clinic portal form

Clinic details

Clinic Name *

Consultant Name

Order sent to *

ClinicDirect to Patient

Patient details

Patient Name *

Patient Surname *

Date of Birth *

Patient Phone Number *

PATIENT ADDRESS

Street address

City

State

Postcode

Email Address *

Clinician Notes:

Patient Script (scripting clinics)

Browse

New or Returning Patient *

New Returning (within 12 months)Returning (over 12 months)

Are you Pregnant or trying to conceive? *

YesNoTryingBreastfeeding

Patient is reordering from their treatment plan notes below

Patients may reorder from their treatment plan within 12 months, please advise whether any adjustments need to be made and how they tolerated their last round

If you are trying to conceive or are breastfeeding, would you prefer pregnancy safe ingredients?

YesNo

Do you have allergies to any Skincare, food or medication? *

Yes No

Are you currently on any medications? *

Yes No

Please include any HRT or contraceptive pill

If yes please specify

If yes please specifiy

Please specify...

I have experienced a reaction to active skincare before

YesNo

Please specify...

Is there any other information you think would be beneficial to disclose to our doctors?

*** If a client is new or has not ordered for 12 months, please upload at least 1 photo of their skin

Photo 1 *

Browse

Photo 2

Browse

Photo 3

Browse

Patient Acknowledgements

1. I understand that prescription-strength ingredients, whilst proven to be effective, can still have variable results between patients. The Secret Skincare is unable to guarantee results.

2. I understand that not all products agree with all patients. Our skincare is individually compounded and all sales are final and not eligible for a refund in cases of change of mind, adverse or allergic reactions and failure to respond to the products.

3. I confirm that I have provided the information requested above in a truthful manner and to the best of my current knowledge. I also understand that providing accurate information is solely my responsibility.

4. The Secret Skincare works with our compounding pharmacy to dispense our custom-formulas. You can choose to fulfil your script through a non-partner pharmacy, get in touch with us info@thesecretskincare.com. If you do so, the price of your treatment may vary.

5. I understand that The Secret products may cause side effects which include, but are not limited to, redness, flaking, dryness and sensitivity. While these side effects are generally mild, short-lived and transient, they can vary in duration and severity from patient to patient. If abnormal irritation occurs, I agree to communicate with The Secret Skincare immediately.

6. I agree to use the The Secret Skincare only as instructed on the label of the product and and read all materials provided by The Secret Skincare prior to use.

7. I understand I may have to cease use of existing products in my regime upon commencing my prescription if the doctors deem their ingredients to be incompatible with my prescribed formula.

8. I understand I will need to use SPF daily whilst using this prescription skincare *

If you would like personalised recommendations: my current routine consists of...

Cleanser

Toner (cease use)

Exfoliator/Mask

Moisturiser

Oil

Eye Treatment

Serum

Sunscreen

Other

Clinic use only - These products may require a call with a practitioner

Estrogen Face Cream 50gm

Estrogen Face Cream Vessel - $200

Skincare sets

Skincare sets Vessels

Essential Set $500 (Day/Night/Eye)Signature Set $600 (Day/Night/Eye/Eye) Hero Set $600 (Day/Night/3 x Base)Other (Please advise combination)

Skincare set Refill

Essential Set $470Signature Set $550Hero Set $550Other

Please specify

Notes for prescriber

Individual Products

Individual 50gm

Night Cream Vessel $200Night Cream Refill $190Estrogen Cream Vessel $200

Individual Products 30gms

Night Cream Vessel $150Night Cream Refill $140

Additional products

Eye Cream Vessel $200Eye Cream Refill $190Spot Treatment Vessel $150Spot Treatment Refill $140

Products that are compounded to order - these do not require a call

These products do not require a call with a practitioner if ordering alone

Day Cream 50gm

Day Cream Vessel $200Day Cream Refill $190

Day Cream 30gm

Day Cream Vessel $150Day Cream Refill $140

Addtional Products

Eye Serum Vessel $200Eye Serum Refill $190Stress Repair Non-Active Vessel $200Stress Repair Non-Active Refill $190

NEW PATIENTS or patients for Estrogen cream:

Please book a call on the next page

Save and Complete Later