Request to purchase | Reverse Time Medical Aesthetics

Request for medical skincare
This form collects your name, email, contact and prescription information, and will be made available only to the prescriber/ doctor, for the purpose of carrying out your request. We will ask for your consent to collect this information, and separately for how we may contact you. Check our Privacy Policy for information about how we store, protect and manage your submitted data.
Protecting your data
We are unable to accept form submissions without express consent from you in the checkbox below, as per data protection regulations (GDPR).
I am 18 or older*
I am 18 or older and I consent to having the clinic collect my details, store and use my information in the manner described above
- Agree
Please contact me by the method(s) selected below:*
At least one selection is required to enable us to respond to you. *Phone calls will be made in working hours.
- Email
- Phone*
Knowing that I can opt-out and change my preferences, I consent to receive relevant notifications:*
*Important notifications are required to be checked in order to allow us to respond.
- Important notifications only - clinic hours, appointment scheduling and remindersChoice
- Product and treatment offerings information monthly update
- Promotional offers - contests, offers on non-prescription treatments.
Name*
Title First Middle Last
Email
Phone
Select subject of enquiry*
Please select from the options in the dropdown list
Comment or Message*
Please enter any other information or comments, including your medical information in this field. If you are requesting eyelash growth serum, please confirm here if you have a history of glaucoma or if you are on any eye treatment.
Please enter your Date of Birth
You should be over 18 years of age to use this service
Date Format: DD dash MM dash YYYY
Do you have any allergies?*
- No
- Yes
Allergies and sensitivities*
If you have answered "Yes" to allergies, please write down the details here.
This form is protected by invisible reCAPTCHA