• MidCPG Healthy Skin e-form

    MidCPG Healthy Skin e-form

    Updated: 15/09/2026

  • Pharmacy Details 

  • Claimant Number*
  • Claimant Number (KE)

  • Patient Information 

  • Date of Birth (Age 2-19)*
     - -
    2 digit day, 2 digit month, 4 digit year

  • SUMBITT BUTTON WILL HIDE - IF HEALTHY SKIN OUTSIDE AGES 2-19 

  • Consultation Details 

  • Date of Consultation *
     - -
    2 digit day, 2 digit month, 4 digit year
  • HEALTHY SKIN PROVIDED.*
  • CONDITION*
  • Option 1: TOPICAL PRODUCT LIST*
  • Option 2: - Referral with Interventions *

  • VERSION 1.0 21/08/2026 

  • AGE DATE CALC - HIDE
     - -
    2 digit day, 2 digit month, 4 digit year
  • PHASE 2 Patients Weight
  • Phase2 DIAGNOSIS
  • PHASE 2 Option 1: FULL CONSULTATION + ANTIBIOTICS + 2x PATIENT FOLLOW-UPs (Must align with consultation form)
  • PHASE 2 - PHOTO UPLOAD OPTIONAL
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