Psoriasis Prescription

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Do you agree and consent to the following?

You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had.
You will disclose any prescription medications you are currently taking and agree to use only one weight loss treatment at a time.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.
Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.
You agree to undergo identification and age verification. This may require submitting valid documents to our approved third-party verification partner for validation.
You consent to EveryDayMeds accessing your Summary Care Record (SCR) for the purpose of ensuring the safe supply of treatment. If the SCR is unavailable or incomplete, you agree to participate in appropriate two-way communication (e.g. phone, secure message, or video consultation) to verify your medical history. If you do not respond or engage, your order will be cancelled.

Your Health

Have you been diagnosed with psoriasis by a clinician?

Yes No

Who first diagnosed your psoriasis?

GP Dermatologist Myself Someone else

When was your psoriasis last reviewed by your doctor?

Within the last year More than 1 year ago

Are your current symptoms the same as when you were first diagnosed?

Yes No

Do you currently have a flare-up of your symptoms?

Yes No

Why are you seeking treatment today?

To manage a flare-up

To try a new medication

To manage ongoing symptoms

First-time treatment

Another reason

In the last 12 months, how many flare-ups have you had?

Less than 4 More than 4

Which parts of your body are affected by psoriasis? (Select all that apply)

Arms

Legs

Chest

Face

Scalp

Nails

Groin

Back

Other

Which area would you like to treat?

Sensitive skin (face, skin folds, or genitalia) Trunk or limbs Scalp

What type of psoriasis do you have (if known)?

Plaque (thick white scales)

Guttate (small red spots)

Scalp

Pustular (pus-filled blisters)

Palmoplantar (soles or palms)

Erythrodermic (rash over the whole body)

I don’t know

Do you have any of the following symptoms?

Fever
Feeling generally unwell
Joint stiffness or pain
Rash affecting more than five handprints of skin
Skin that is leaking pus or appears infected

Yes No

Do you have any of the following serious symptoms?

Redness covering more than 90% of your body
Severe worsening of your psoriasis
Pus-filled blisters related to your psoriasis
Fever-like symptoms (e.g. hot/cold, fast heart rate or breathing)

Yes No

Do you experience any of the following? ⚠️ You can proceed, but we recommend you also consult your GP or dermatologist.

Poor response to past treatments

Severe symptoms

Psoriasis affecting more than 10% of your body

Significant impact on your mental health or confidence

Do any of the following apply to you?

Swollen joints
A doctor has diagnosed you with arthritis
Your fingernails or toenails have holes or pits
Heel pain
A finger or toe has been swollen and painful without an obvious cause

Yes No

Do you have any of the following known triggers or contributing factors?

Stress
Smoking, alcohol, or obesity
Skin injury or recent surgery
Recent infections (e.g. Streptococcus or HIV)
Use of medications like lithium, beta-blockers, terbinafine, or hydroxychloroquine

Yes No

Please upload 1 clear photo of the affected area(s).

These images help our clinical team assess your condition. Images are deleted securely after 15 days.

Medical Condition

Do you have any of the following medical conditions?

Liver disease
Kidney disease
High blood calcium levels

Yes No

please provide the following details:

Which condition you currently have
Whether you have used psoriasis treatments while having this condition
When you last saw your GP about it

Have you used any treatments for your psoriasis, currently or in the past?

Yes No

What treatments are you currently using? Include any of the following that apply:

Emollients (moisturisers)

Steroid creams

Coal tar products

Oral tablets

Injections

Vitamin D preparations (e.g. Dovonex, Enstilar)

Other

Have you previously used any of the following treatments?

Enstilar Foam

Diprosalic Scalp Application

Diprosalic Ointment

Bettamousse

Silkis Ointment

Dovonex Ointment

Wynzora Cream

Calcipotriol Ointment

Dovobet

Medication

Are you currently taking any medications (prescription, over-the-counter, or recreational)?

Yes No

Are you currently taking any of the following medications?

Lithium

Thiazide diuretics (e.g. bendroflumethiazide, chlortalidone)

Digoxin

Calcium-based antacids (e.g. Rennie, Settlers)

Please provide more information about these medications:

The condition you're treating
The name of the medication
The dose
Whether you’ve used psoriasis treatments at the same time in the past

Do you have any known allergies or sensitivities?

Yes No

Please specify what you're allergic or sensitive to.

Do any of the following apply to you?

Any other medical conditions not already mentioned
Mental health disorders requiring specialist care or hospitalisation
History of major surgery
Heart problems or previous stroke
Decreased kidney or liver function

Agreement

Do you confirm the following?

You have answered all questions truthfully and accurately
You are using this service for your personal care only
You understand the condition, treatment options, and all potential risks and side effects
You give informed consent to treatment
You will read the patient information leaflet before using any medication
You will not use this treatment if it is contraindicated for you or if you have questions about its suitability

Yes No

Do you give us permission to access your NHS Summary Care Record or request medical history from your GP if required?

Yes No

Do you consent to us sharing relevant consultation details with your GP to ensure continuity of care?

Yes No

GP Consultation

We can notify your GP of your treatment for you. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to EveryDayMeds contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Identity Verification

Please upload your identification documents.

Would you like to upload documents now?

Upload now Upload later

What you need to upload

To safely prescribe weight-loss medication, our clinicians need to verify your identity and assess your eligibility. Please upload both of the following:

Photo ID

Upload a clear photo of one valid ID document, such as:

Passport
UK driving licence
National ID card

Requirements:

The full document must be visible
Text and photo must be clear and readable
The ID must be valid (not expired)

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Tap to upload ID card

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Full-Body Photo

Take a full-body photo of yourself using your camera.

Photo guidelines:

Full body visible (head to feet)
Wear fitted clothing (no coats or baggy clothes)
Stand straight, facing the camera
No filters or edits

This photo is used only to help our clinicians assess your BMI and suitability for treatment.

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Take photo using camera

Camera required

Upload Previous Prescription

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Upload previous prescription

No file chosen

If you select this option, your order won’t be approved until all required documents are submitted. After your consultation, we’ll email you instructions on how to upload your documents.

Your Psoriasis Prescription Plan

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