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ABOUT YOU

Have you previously been diagnosed with mild to moderate acne by a medical doctor?

YOUR HEALTH

Are you allergic to any of the following?

  • Clindamycin
  • Lincomycin
  • Benzoyl peroxide

Do any of the following apply to you:

  • I take neostigmine or pyridostigmine (used for conditions such as Myasthenia Gravis)
  • I am likely to have an operation whilst I am on Duac
  • I was hoping to get Oral Typhoid vaccine whilst on Duac

Are you pregnant, planning on becoming pregnant, or breastfeeding?

Do you have acute porphyria?

  • a rare hereditary disease affecting haemoglobin

Do you currently have sunburn?

YOUR MEDICATION

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

AGREEMENT

Do you understand that it can take 4-8 weeks of treatment before beneficial effects are seen?

Do you understand that treatment with Duac should not exceed 12 weeks?

Do you understand that you should use Duac at most once a day, after washing your face with a mild cleanser and fully drying?

Do you understand if your acne gets worse or starts to cause scarring, you must see your GP?

Do you understand that if severe erythema (severe redness), dryness, itching or burning of the affected area occurs, Duac gel should be discontinued?

Do you understand that this medication can make your skin more sensitive to sunlight (photosensitivity)? You should avoid sunlight and sunlamps while using this gel and take care to use sunscreen and cover in protective clothing if sunlight exposure is necessary.

Do you understand that if your get prolonged or significant diarrhoea, that treatment should be stopped immediately?

Do you understand that this medicine must not come in contact with eyes, mouth, mucus membranes, or eczematous/ broken/ sunburned skin, and that if it does by accident you should seek medical advice?

Do you agree to the following?

  • You will read the patient information leaflet supplied with your medication.
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use.
  • You give permission to access you NHS Summary Care Record in order to identify you correctly, check your medical history and provide the best possible care.
  • You give permission to contact your GP to inform them of your treatment.
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
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