Uncouth Skincare Consultation

YOUR SKINCARE CONSULTATION

Before we start your skincare consultation, we need to know if you currently live in the UK and that you are happy for us to hold onto your health data. We promise to look after it.

I currently live in the UK and agree to Uncouth holding my health data.

I am 16 or over

existing customer?

If you've already registered, login here. Filling this form in twice is silly.

for you

Already used to a certain strength of formula - we'll ask about this at the end of this consultation.

start date

Don't want to start right now ... pick a start date that works for you!

What would you like us to sort?

Anti-ageing Bespoke Formulations

Acne Bespoke Formulations The Hormonal Acne Pill The Acne Pill

Hyperpigmentation Bespoke Formulations

Rosacea Bespoke Formulations The Rosacea Pill

Just glow me up!Bespoke Formulations

a picture tells a thousand words

Add three photos at the end of the consultation. Or upload later if you’re out and about but we'll need these in order to prescribe.

If you had to choose one for us to focus on the most?

Acne

Oiliness

Uneven texture

Enlarged pores

Anti-ageing

Rosacea

Hyperpigmentation

Just glow me up!

What was your sex at birth?

We're not being uncouth! We just need to know if there is a chance you could become pregnant. We appreciate that the gender you identify as may be different.

Male

Female

What is your date of birth?

You have to be 16 or above to use our service. Please make sure you give us the correct date of birth as we need this for your prescription.

Which areas of your face are affected?

Forehead

Nose

Cheeks

Chin

Jawline

Which of these pictures is closest to your acne?

Mild - I only get a few spots and/ or whiteheads and blackheads

Moderate - I get quite a lot of spots and they can become inflamed

Severe - I suffer from extensive spots and cysts

Do your spots leave you with uneven skin tone (dark or red marks)?

Yes

No

Not Sure

Do you suffer with acne scars?

Yes

No

Not Sure

Do you experience hormonal breakouts (an increase in spots around the time of your period)?

Yes

No

Not applicable

Don't know

Do you feel that your face looks red, more so than other people's?

Yes

No

Do you often experience facial flushing, for example after drinking alcohol or when stressed?

Yes

No

Do you suffer with spots?

Yes

No

Some people with rosacea experience dry eyes. Does this sound like you?

Yes

No

Have you used any steroid creams on your skin in the last 4 weeks?

Sometimes steroid creams can cause a rash similar to rosacea

Yes

No

Do you suffer with lupus?

Yes

No

Do you have any of the following symptoms - persistent diarrhoea, wheezing, abdominal pain?

Yes

No

Tick any of the below that apply to you

I would like to improve fine lines

I would like to improve my skin's elasticity and/or firmness

I would like my skin to look brighter

I would like to improve sun damage

I want to focus on prevention of skin ageing

Would you like us to treat any areas of pigmentation?

By pigmentation, we mean dark spots, freckles or melasma.

Yes

No

Not Sure

We understand you want your skin to glow! Do any of the below apply to you?

You can tick more than one

I'd like to improve the appearance of fine lines

I'd like to improve my skin's elasticity/ make it look more firm

I'd like to even out my skin tone

None of the above - just more glow please!

How would you describe your skin tone?

Pale, white skin. Always burns, never tans.

Fair skin. Usually burns, rarely tans.

Darker white skin. Tans gradually, sometimes burns.

Light brown skin. Rarely burns, tans with ease.

Brown skin. Very rarely burns, tans very easily.

Dark brown, black skin. Never burns, tans very easily.

Which areas of your face are affected by hyperpigmentation?

You can tick more than once

Forehead

Nose

Cheeks

Chin

Jawline

Do you know what the cause of your hyperpigmentation is?

Common types of hyperpigmentation are dark marks secondary to acne, larger dark patches secondary to melasma or secondary to ageing or sun exposure (sun spots, background freckling)

Yes, dark marks secondary to acne

Yes, melasma

Yes most likely secondary to ageing

Unsure

Are you suffering with active acne?

It is important we get your acne under control as well as treating your hyperpigmentation.

Yes

No

Sometimes large pores go hand in hand with blemish prone skin. How often do you suffer with spots?

Not very often

I get occasional breakouts

I suffer with a lot of spots

Which areas of your face are affected by oiliness?

You can tick more than once

Forehead

Nose

Cheeks

Chin

Jawline

Some people find that their skin is oily around their T-zone (central face) but can be dry in other parts of their face.

Yes, this sounds like me

No, it's mostly oily

Which of the below is most applicable?

I rarely suffer with spots

I get occasional spots

I suffer from frequent breakouts

Which areas of your face are affected by uneven texture?

You can tick more than once

Forehead

Nose

Cheeks

Chin

Jawline

Does the skin on your face feel rough, bumpy or flaky?

Yes

No

Sometimes

Not Sure

Do you suffer with spots?

Yes, mainly blackheads and whiteheads

Yes, I get a few inflamed spots

Yes, I get lots of spots

No

Which of the following best describes your skin?

Oily

Dry

Combination

Normal

Not Sure

Would you describe your skin as sensitive?

Does it easily react to skincare products?

Yes

No

Not Sure

Do you have any other active skin conditions affecting your face?

By this we mean conditions like eczema, psoriasis, lupus or skin cancer

Yes

No

Are you currently pregnant, breastfeeding or planning on becoming pregnant in the near future?

We need to know because some prescription ingredients shouldn't be used in pregnancy or whilst breastfeeding.

Yes, I'm pregnant

Yes, I'm breastfeeding

Yes, I'm planning to conceive

No, none of the above

Disclaimer

Some ingredients shouldn't be used when you are pregnant or breastfeeding (such as tretinoin, adapalene, hydroquinone, spironolactone and certain types of topical and oral antibiotics). The good news is we have some very effective topical formulas that are considered safe to use in pregnancy and when breastfeeding. At Uncouth, we ensure that this is highlighted to our medical team and that you receive a doctor approved, pregnancy safe formula that is also suitable to use when breastfeeding.

I have read the above information and am happy to go ahead

Have you used any prescription creams in the last 3 months?

Yes

No

Which prescription creams have you used?

Tick any that apply

Tretinoin (e.g Retin A or other personalised formulas)

Hydroquinone creams

Tretinoin + Clindamycin (Treclin)

Erythromycin + Zinc Acetate (Zineryt)

Benzoyl Peroxide + Clindamycin (Duac)

Isotretinoin gel (Isotrex)

Adapalene (Differin)

Azelaic acid (e.g Finacea, Skinoren or other personalised formulas)

Metronidazole (Rozex, Metrogel)

Ivermectin (Soolantra)

A steroid cream

Adapalene + Benzoyl Peroxide (Epiduo)

None of the above

Disclaimer

We would not advise doubling up on prescription treatments. If you are still using a prescription cream or creams and would like to use our treatment instead, we would suggest checking with your original prescriber to ensure that you are ok to switch!

I have read the above information and am happy to go ahead

Are you currently using Tretinoin?

Yes

No

What strength of Tretinoin have you used?

0.009%

0.015%

0.025%

0.05%

0.1%

Not Sure

Did you tolerate this strength?

Yes and I was using it every night

Yes, but only if I used it intermittently

No, it was too strong

Not Sure

Have you taken any prescription tablet medications for your skin?

Like oral antibiotics, isotretinoin (Roaccutane) or spironolactone

Yes

No

Have you used any of the below prescription tablets in the last three months?

Tick any that apply

Isotretinoin (Roaccutane) tablets

Tetracycline

Minocycline

Lymecycline

Oxytetracycline

Doxycycline

Trimethoprim

Erythromycin

Spironolactone

The contraceptive pill

None of the above

Did Isotretinoin (Roaccutane) tablets help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Isotretinoin (Roaccutane) tablets?

Yes

No

How long ago did you use Isotretinoin (Roaccutane) tablets?

I am taking it now

Less than 3 months ago

Over three months ago

Did Tetracycline help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Tetracycline?

Yes

No

How long ago did you use Tetracycline?

I am taking it now

Less than 3 months ago

Over three months ago

Did Minocycline help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Minocycline?

Yes

No

How long ago did you use Minocycline?

I am taking it now

Less than 3 months ago

Over three months ago

Did Lymecycline help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Lymecycline?

Yes

No

How long ago did you use Lymecycline?

I am taking it now

Less than 3 months ago

Over three months ago

Did Oxytetracycline help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Oxytetracycline?

Yes

No

How long ago did you use Oxytetracycline?

I am taking it now

Less than 3 months ago

Over three months ago

Did Doxycycline help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Doxycycline?

Yes

No

How long ago did you use Doxycycline?

I am taking it now

Less than 3 months ago

Over three months ago

Did Trimethoprim help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Trimethoprim?

Yes

No

How long ago did you use Trimethoprim?

I am taking it now

Less than 3 months ago

Over three months ago

Did Erythromycin help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Erythromycin?

Yes

No

How long ago did you use Erythromycin?

I am taking it now

Less than 3 months ago

Over three months ago

Did Spironolactone help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with Spironolactone?

Yes

No

How long ago did you use Spironolactone?

I am taking it now

Less than 3 months ago

Over three months ago

Did the contraceptive pill help your skin?

Yes

No

Not Sure

Did you experience any significant side effects with the contraceptive pill?

Yes

No

How long ago did you use the contraceptive pill?

I am taking it now

Less than 3 months ago

Over three months ago

Do you have any medical conditions?

It’s important we know if you have any medical issues such as heart, kidney or liver disease

Kidney disease

Heart disease

Liver disease

Anything else

No

Do you take any regular medications?

It’s important we know if you are on any regular medications including any supplements

Yes

No

Do you have any allergies that we should be aware of?

Yes

No

We want to know if you have any allergies to prescription medications or prescription creams. You can find a list of the base ingredients in our creams on our ingredient list. None of our prescription products contain fragrance.

What do you use in your current skincare routine?

Cleanser

Moisturiser

Exfoliants (e.g glycolic or lactic acid)

A non prescription retinoid (e.g retinol / retinal)

None of these

Do you use an SPF as part of your daily skin routine?

Yes

No

Disclaimer

We'd recommend you always use a high protection SpF (30 or above) as part of your daily skincare routine.
This is even more important when you start using your custom formula because some of our active ingredients can make your skin more sensitive to the sun.

I have read the above information and am happy to go ahead

DO YOU HAVE A PREFERENCE FOR YOUR INGREDIENTS?

We still need to review your consultation and photos so we can make sure we prescribe you the best treatment but it's helpful to know if there is a treatment option you would prefer.

No, I'm new to all of this. I'm happy for my dermatology team to decide

Yes, I do

Do you have a preference for the strength of tretinoin?

We'd always recommend starting low and building up but we understand you may have used tretinoin before.

Your prescriber may increment the strength of your next formula as part of your treatment plan. If you’d like on the same strength you can control this within your dashboard..

No, I'm happy for the uncouth dermatology team to decide.

Tretinoin 0.015%

Tretinoin 0.025%

Tretinoin 0.05%

Tretinoin 0.1%

Is there anything else you would like our dermatology team to know?

Do you have any alergies or intolerances?

Tretinoin

Azelaic acid

Niacinamide

Hyaluronic acid

Adapalene

Clindamycin

Tranexamic acid

Azelaic

Hydroquinone

Spironolactone

Ivermectin

Metronidazole

Doxycycline

Erythromycin

Lymecycline

Hydrocortisone

Trifarotene

Tirzepatide

Semaglutide

If yes, please provide details. Or, do you have a particular preference for one of our active ingredients?
We can't make any promises but we will do our best to accommodate!

Disclaimer

I understand that Uncouth's medical team use this information to determine the safest and most appropriate treatment. If certain medical questions have been answered incorrectly it could have a negative impact on my skin and/or my health.

Uncouth creates personalised prescription creams which fall under the definition of unlicensed medications. Certain treatments may be used off-licence for the treatment of acne or rosacea.

I understand that Uncouth does not screen for any skin cancers.

I understand that my prescription formula is for my own use only and I will read the patient information leaflet supplied with my medication. I will inform Uncouth and my GP if I experience any significant side effects of treatment, if I develop a new medical condition or if I start a new medication.

I will read the patient information leaflet supplied with my medication and have read the information above.

Do you have a treatment preference?

Dr. Emma Horton

Uncouth Founder & CEO

If you have any preferences, it would be helpful to know before our dermatology team reviews your photographs and consultation to make the final decision.

If applicable, you can select both creams and tablets.

CLARITY
Tretinoin / Clindamycin 1% / Tranexamic 5%

SOOTHE
Ivermectin 1% / Niacinamide 4% / Azelaic acid 10%

BOOST
Tretinoin / Azelaic Acid 4% / Niacinamide 4% / Hyaluronic acid 0.25%

TRANSFORM
Tretinoin 0.025% / Hydroquinone 6% / Hydrocortisone 1%

TRANSFORM +
Tretinoin 0.025% / Hydroquinone 8% / Hydrocortisone 1%

BRIGHTEN
Tretinoin 0.015-0.1%
Azelaic acid 4%
Tranexamic acid 5%
Hyaluronic acid 0.25%

REJUVENATE
Adapalene 0.3%
Niacinamide 4%
Hyaluronic acid 0.25%

SERENITY
Spironolactone 5% / Tranexamic acid 4%

Spironolactone Formulas are £59.99 for 15mls (refill every 1 month)

THE HORMONAL ACNE PILL
Pairs well with CLARITY, SERENITY OR BOOST

Oral Spironolactone

£60 for a 3 month course.

THE ACNE PILL
Pairs well with REJUVENATE

Doxycycline Antibiotic Tablets

£35 for a 3 month course.

THE ACNE PILL
Pairs well with BOOST

Erythromycin Antibiotic Tablets

£35 for a 3 month course.

THE ACNE PILL
Pairs well with BOOST

Lymecycline Antibiotic Tablets

£45 for a 3 month course.

THE ROSACEA PILL
Pairs well with SOOTHE

Slow Release Doxycycline

£80 for a 3 month course.

Let my dermatology team decide

Need help?
Email us on enquiries@uncouthskincare.co.uk

Which formula would you prefer?

Dr. Emma Horton

Uncouth Founder & CEO

We’re always transparent about our formulations. If you have any preferences, it would be helpful to know before our dermatology team reviews your photographs and consultation to make the final decision.

Heads up, our dermatology team will have the final say

Tretinoin / Tranexamic / Azelaic

Adapalene / Clindamycin / Niacinamide

Spironolactone / Tranexamic

Topical spironolactone can be prescribed if other topical acne treatments have been ineffective.
Spironolactone formulas are £59.99 for 15mls, expiry 1 month.*

Let my dermatology team decide

Do you have a formula preference?

Heads up, our dermatology team will have the final say

Tretinoin / Azelaic Acid / Niacinamide / Hyaluronic acid

Tretinoin / Azelaic acid / Tranexamic acid / Hyaluronic acid

Let my dermatology team decide

Dark Spot Formula (hydroquinone 6%) can be added at checkout

Hydroquinone cream should be limited to 3-4 months of use at a time, followed by a three-month break.

Do you want us to consider you for dark spot formula?

Dark spot formula is hydroquinone cream 6%*

Yes

No

I'd like dark spot formula on its own

Let my dermatology team decide

Anything else?

Is there anything else we should know before writing your prescription? For example tell us the strength you’d prefer to start on if you haven’t already*

*Tretinoin strengths:
0.015%, 0.025%, 0.05%, 0.1%
Hydroquinone formulas are available in tretinoin strength 0.025%.
Prescription subject to dermatological assessment.

Would you like us to tell your GP about any treatment we give you?

Yes

No

Have you had a routine blood test recently and were they normal?

Yes - they were normal

Yes - they were abnormal

No

We're almost there

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