Prescription Consultation Form

Before we can process your prescription order, we need to gather some important information about your health. All information is treated in strict confidence and reviewed by our prescribing clinician at Soni Skin Care Clinic.

Why do we need this? Prescription-strength skincare contains active pharmaceutical ingredients. To ensure they are clinically appropriate and safe for you, our clinician must review your medical history before a prescription can be issued.

About You

First Name*

Last Name*

Email Address*

Contact Number*

Date of Birth*

I confirm I am over 18 years of age*

Your Skin Type (Fitzpatrick Scale)

Please select the skin type that best matches you.

Type I — Always burns, never tans (very fair) Type II — Usually burns, sometimes tans (fair) Type III — Sometimes burns, usually tans (medium) Type IV — Rarely burns, always tans (olive) Type V — Very rarely burns, dark brown skin Type VI — Never burns, deeply pigmented

Prescription Request

What is your main reason for requesting a prescription? (select all that apply)

Safety & Consent

Are you currently pregnant or breastfeeding?*

No Yes Prefer not to say

I confirm this prescription is for my personal use only* I agree to inform my regular GP or doctor about this treatment* I understand that Obagi prescription products require daily commitment and consistent sun protection* I am aware that waxing or laser treatments on areas being treated should be avoided during treatment* I consent to a prescribing clinician at Soni Skin Care Clinic reviewing my information and prescribing if deemed clinically appropriate* I acknowledge that patch testing new products before full application is strongly recommended*

Photo of Skin Concern (Optional)

Upload a photo of the area you would like treated

JPG or PNG only — max 5MB. Helps our clinician assess your skin concern.

By submitting this form you confirm that all information provided is accurate and complete to the best of your knowledge.