1. Eligibility & Safety

• I am not allergic to Clindamycin (or related lincosamides like Lincomycin), Tretinoin, Aloe, or common topical bases (e.g., propylene glycol, alcohols, parabens, fragrance). If I have allergies, I will list them during intake.
• I am not pregnant or breastfeeding, and I will inform my provider if I plan pregnancy.
• I confirm the treatment areas do not have open wounds, active infection, or severe irritation, and I will not apply the cream to such areas.

2. Medical History & Screening

• I will disclose any drug or topical product allergies.
• I will state my main goal (reduce active acne, improve acne scars/texture, both), describe my current concerns & duration (e.g., whiteheads/blackheads, inflammatory bumps, post-acne marks), and list the areas to treat (e.g., face, neck, back, chest).
• I will upload a clear, well-lit photo of the affected skin area.
• I will disclose if I have ever had severe diarrhea or colitis associated with antibiotics (e.g., C. difficile), and describe details if applicable.
• I will list all medications and supplements I take (dose if known) and disclose any medical conditions affecting skin healing/sensitivity (e.g., severe eczema/dermatitis, psoriasis, active rosacea flare, photosensitivity disorders, keloid tendency).

3. Prior/Current Skincare & Treatments

• I will report whether I previously used topical retinoids (tretinoin/retinol) or topical antibiotics for acne (with products, duration, and any side effects).
• I will report if I currently use other active skincare (e.g., benzoyl peroxide, AHAs/BHAs like glycolic/salicylic acid, azelaic acid, steroids) or had recent peels/laser/microneedling/waxing (include dates if possible).
• I will disclose if I have taken oral isotretinoin (Accutane) in the past 6 months (month/year and dose if known).

4. How to Use & Key Precautions

• I understand Tretinoin increases photosensitivity; I will use daily broad-spectrum SPF 30+, limit UV exposure/tanning, and follow nighttime use as directed.
• I understand topical Clindamycin should be used as directed to reduce antibiotic resistance; I will stop and seek care if I develop severe or persistent diarrhea/abdominal cramps or severe skin irritation.
• I will apply a thin layer to intact skin only, avoid eyes/lips/mucosa, wash hands after use, and avoid layering strong actives at the same time unless instructed.

5. How the Medication is Provided

• I understand this cream may be compounded using USP-grade ingredients; the specific combination/strengths may be off-label.
• My instructions (amount/frequency/duration) will be individualized by the provider.

6. Identification & Confidentiality

• Uploading a valid government-issued photo ID is a legal requirement to verify my identity before the consultation can be completed.
• This verification complies with state and federal telemedicine regulations.
• My personal information and ID will be handled securely, stored confidentially, and never shared except as required by law or to provide my medical care.

IMPORTANT: Please keep a clear image of your Driver’s License / State ID / Passport (or photo of any government-issued ID) ready on this device to upload.

7. Consent

• I give my full consent for RightMD INC and its affiliated medical/pharmacy teams to prescribe and dispense this compounded acne/acne-scar cream based on the information I have provided.

8. Payments & Refund Policy

• All purchases and services are final and non-refundable.

9. Policies

• I have read and agree to the Terms & Conditions, Privacy Policy, and Refund & Cancellation Policy.