About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
Do you have eczema or psoriasis
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Women only: Are you breast feeding?
Do you get eczema or psoriasis on your face or eyes?
Have you ever had an allergic (hypersensitive) reaction to betamethasone valerate or any other creams?
If yes, please describe the product/reaction
Are you or are you going to be applying the cream under an airtight dressing?
Do you have chronic leg ulcers
Do you have any allergies?
If yes, please provide details
Do you have eczema or psoriasis on a large area of your body?
Have you ever suffered from blurred vison whilst receiving systemic and topical corticosteroids?
Do you have eczema or psoriasis on broken skin or within skin folds?
Do you have any of the following?
- Itchy skin without inflammation
- Itching around any private parts
- Infected skin
- Flushing of skin on or around your nose (rosacea)
- Spotty red rash around your mouth (perioral dermatitis)
Do you have any untreated bacterial, fungal or viral skin lesions?
Do you have persistent eczema or hand eczema?
Please provide details of any recent or past medical history of note (e.g. liver or kidney problems)
Please list all your current prescription medication including any medication you buy over the counter...
Please provide details of any recent or past medical history of note
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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 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.