Skincare Intake Form — City Life Pharmacy

Step 1 of 5

Patient Information

Your information is kept strictly confidential and used only for your telehealth consultation with our pharmacy team at City Life Pharmacy & Compounding Centre.

Personal details

First name *

Last name *

Date of birth *

Must be 18 years or older

Biological sex *

Relevant for some medications

Email address *

Phone number *

Province *

Identity verification

Upload government-issued photo ID *

Required for telehealth verification. Accepted: driver's licence, passport, health card (front). File types: JPEG, PNG, PDF (max 10 MB).

📄

Click to upload or drag & drop

JPEG, PNG, or PDF · Max 10 MB

Pregnancy status

Are you currently pregnant or breastfeeding? *

Yes — pregnant or breastfeeding

Trying to conceive

Not applicable

Step 2 of 5

Primary Skin Concern

Select the condition you'd like to address. Our licensed pharmacists compound each formulation specifically for your concern.

Select your concern

✨

Anti-Aging

Tretinoin 0.25% · Niacinamide 4% · Hyaluronic Acid 0.5%
Estriol 0.3% · Ascorbic Acid 1–2%

🌿

Acne

Spironolactone 5% · Clindamycin 1% · Niacinamide 4%

☀️

Dark Spots & Hyperpigmentation

Hydroquinone 4% · Kojic Acid 4% · Ascorbic Acid 2% · Desonide 0.05%

🌸

Scars

Fluocinolone 0.1% · Verapamil 3% · Pentoxifylline 0.3%

🍃

Rosacea

Azelaic Acid 10% · Metronidazole 1% · Niacinamide 4%

👁️

Eye Cream

Caffeine 1% · Hyaluronic Acid 0.5% · Chrysin 2%

Step 3 of 5

Health & Medical History

Your safety is our highest priority. These questions allow our pharmacists to identify whether our compounded preparations are appropriate for you.

General medical history

Known drug or cosmetic allergies? *

No known allergies

Yes, I have allergies

Current medications or supplements *

Existing skin conditions *

Eczema / atopic dermatitis

Psoriasis

Rosacea

Lupus or autoimmune skin condition

None of the above

⚠️

Anti-aging formulation questions — The following relate to Tretinoin, Estriol, and Ascorbic Acid in your treatment. Please answer carefully.

Retinoid & hormone history

Previous retinoid use (Retin-A, tretinoin, isotretinoin/Accutane)? *

No, never

Yes, tolerated well

Yes, had a reaction

Accutane within last 6 months

History of hormone-sensitive conditions? *

Breast cancer, uterine cancer, endometriosis — relevant for Estriol

Yes

Currently on hormonal therapy or birth control? *

Yes

Vitamin C sensitivity or history of kidney stones? *

Yes

⚠️

Acne formulation questions — The following relate to Spironolactone, Clindamycin, and Niacinamide in your treatment.

Spironolactone safety screening (female / other patients)

History of kidney disease or adrenal insufficiency? *

Relevant for Spironolactone (potassium-sparing diuretic)

Yes

High potassium (hyperkalemia) or taking potassium supplements? *

Yes

Currently taking ACE inhibitors, ARBs, or NSAIDs? *

Significant interaction with Spironolactone

Yes

Not sure

Clindamycin safety screening

Prior reaction to lincosamide antibiotics (clindamycin, lincomycin)? *

Yes

History of Crohn's disease or ulcerative colitis? *

Clindamycin significantly increases risk of C. difficile colitis in IBD patients

Yes

⚠️

Hyperpigmentation formulation questions — The following relate to Hydroquinone, Kojic Acid, Ascorbic Acid, and Desonide in your treatment.

Hyperpigmentation treatment safety screening

Prior hydroquinone use? *

No, never

Yes, no issues

Yes, had a reaction

History of ochronosis? *

Paradoxical skin darkening from long-term hydroquinone use

Yes

History of glaucoma, diabetes, or Cushing's syndrome? *

Relevant for Desonide corticosteroid component

Yes to one or more

Currently using other topical corticosteroids on the face? *

Yes

⚠️

Scar formulation questions — The following relate to Fluocinolone (corticosteroid), Verapamil (calcium channel blocker), and Pentoxifylline.

Scar treatment safety screening

Type of scar being treated? *

Keloid scar

Raised, grows beyond wound boundary

Hypertrophic scar

Raised, stays within wound boundary

Atrophic / depressed scar

Sunken or pitted (e.g. acne scars)

Unsure

History of heart conditions, arrhythmia, or low blood pressure? *

Relevant for Verapamil (calcium channel blocker)

Yes

Are you taking any of the following? *

Verapamil has significant drug interactions with these

Beta-blockers (metoprolol, atenolol, etc.)

Statins (simvastatin, atorvastatin, etc.)

Digoxin

None of the above

History of liver disease or bleeding disorder? *

Relevant for Pentoxifylline

Yes

History of glaucoma or Cushing's syndrome? *

Relevant for Fluocinolone (corticosteroid)

Yes

⚠️

Rosacea formulation questions — The following relate to Azelaic Acid 10%, Metronidazole 1%, and Niacinamide 4% in your treatment.

Rosacea treatment safety screening

Have you been diagnosed with rosacea by a physician or dermatologist? *

Yes, formally diagnosed

Self-diagnosed / suspected

Which symptoms do you experience? *

Facial flushing / persistent redness

Papules or pustules (acne-like bumps)

Visible blood vessels (telangiectasia)

Eye irritation / ocular rosacea

Known allergy to metronidazole or imidazole medications? *

Yes

Currently taking oral anticoagulants (e.g. warfarin)? *

Metronidazole can potentiate warfarin's anticoagulant effect

Yes

History of blood disorders or liver disease? *

Relevant for Metronidazole metabolism and safety

Yes

⚠️

Eye Cream formulation questions — The following relate to Caffeine 1%, Hyaluronic Acid 0.5%, and Chrysin 2% for under-eye concerns.

Eye cream safety screening

Primary under-eye concern? *

Puffiness / bags under the eyes

Dark circles

Fine lines / crepey skin

All of the above

Known caffeine sensitivity? *

Yes

Existing eye conditions (glaucoma, dry eye, blepharitis)? *

Yes

Recent eye surgery (LASIK, cataract, etc.) in the last 6 months? *

Yes

Step 4 of 5

Your Skin Profile

Help us personalize your treatment plan with a few questions about your skin and lifestyle.

Skin type & history

Skin type *

Dry

Tight, flaky, dull

Oily

Shiny, enlarged pores

Combination

Oily T-zone, dry cheeks

Sensitive

Reacts to products easily

How long have you had this concern? *

Previous treatments tried *

None — first treatment

Over-the-counter products

Prescription treatments

In-office procedures

Sun protection & lifestyle

Daily sunscreen use (SPF 30+)? *

Yes, every day

Sometimes

Rarely / never

Most compounded skincare formulations increase photosensitivity — daily SPF 30+ will be required.

Smoking or significant alcohol use? *

No to both

I smoke

Heavy alcohol use

Additional information

Anything else you'd like us to know?

Step 5 of 6

Review & Pay

Please review your information, complete payment, then submit your intake form to our pharmacy team.

Patient Information

Full name—

Date of birth—

Email—

Phone—

Treatment Selected

Primary concern—

Payment

Amount due

$0.00 CAD

—

Secure payment powered by PayPal. You can pay with PayPal or any major credit card.

Unable to Proceed at This Time

Based on your answers, one or more contraindications have been identified with our compounded formulation. Your health and safety come first — please consult your physician before proceeding.

Clinical reason flagged

City Life Pharmacy & Compounding Centre · 35 Lower Simcoe St, Toronto, ON · (416) 214-2489

✓

Intake Form Received

Thank you! Our pharmacy team at City Life will review your submission and contact you within 1–2 business days to discuss your compounded skincare options.

What happens next

1Licensed pharmacist reviews your intake form

2We contact you to confirm eligibility & discuss your treatment

3Prescription obtained & compound prepared in our lab

4Pickup at 35 Lower Simcoe or free delivery arranged

Questions? Call (416) 214-2489 or visit citylifepharmacy.com

Compounded Skincare Consultation