Differin Adapalene Gel 0.1% 30g

1) Could we please have the name and physical address of the patient, if not already provided, or if you are ordering for someone else?

2) Have you or the patient had this product before?

3) Could we please have your date of birth/age?

4) If applicable, are you pregnant or breastfeeding? If so, at what stage?

5) Are you (or the patient using this medicine) on any medications or have any health conditions?

6) This medicine is only licensed for SEVERE ACNE ONLY. please confirm this is what it is being used for?

7) What are you symptoms, if applicable?

8) Any allergies to medications?