Consultation

Are you aware you should see a doctor for a diagnosis of Rosacea BEFORE using Mirvaso gel?

Are you aware Mirvaso should be started carefully to avoid worsening rosacea?

Are you aware Mirvaso usually improves symptoms in 70% OF PEOPLE?

Mirvaso will not work for everyone.

Are you aware Mirvaso can actually worsen symptoms in some people (up to 16% of people)?

Worsening of redness can occur soon after Mirvaso is applied or later when the effects are wearing off (after 8 to 12 hrs). Most people recover on stopping treatment.

Have you been diagnosed with a medical condition causing significant low blood pressure?

This applies mainly to severe uncontrolled heart disease.

Are you taking an antidepressant of the following type?

• An antidperessant of the MAOI type (e.g. selegiline or moclobemide)
• A tricyclic antidepressant (such as imipramine) or tetracyclic (such as maprotiline, mianserin, or mirtazapin)

NOTE: Most antidepressants are NOT of these types. Please check with your doctor if you are not sure.

Have you been diagnosed with any of the following:

• Liver or kidney disease – no including simple water infections
• Sjorgen’s  syndrome (uncommon immune condition causing dry skin)
• Poor circulation to the hands or feet

Are you pregnant or breast feeding or intending to become pregnant?

Are you aware Mirvaso should NOT be applied close to the eyes or lips or to open sores?

Are you aware Mirvaso should be stopped and a doctor consulted if symptoms are worsening or you experience side effects?

Do you have any further questions you need to ask?

Do all the following apply to you?

• The medication is for my own use
• I will read the information leaflet supplied with the medication
• I am over 18 and I agree to identity verification checks
• I have completed this questionnaire myself and fully understand all the information
• My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment
• I agree to the terms & conditions, privacy policy, & data sharing policy

What is the name of your GP surgery and do you consent to us contacting them about your treatment?

Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability.