Online Skin Consultation - Fitzgerald Private Clinic

Redeemable Email Consultation Fee

Price: 30,00 €

Fully redeemable fee of €30 for email skincare advice from our specialist skincare team. You will be sent a code with your email response to redeem your €30 on your online purchases. Link to purchase at top of this page. Thank you.

Personal Contact Details*

First Name *

Last Name *

DOB *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Phone *

I would like to be contacted to arrange a...(please choose one) *

Email response (€30 redeemable charge)
Not available during Covid restrictions - Clinic Visit with Nurse/Therapist
Not available during Covid restrictions - Clinic Visit to Doctor

I am interested in...(Click the image(s) that apply) *

Skincare
(Environ/Obagi/Peels/Advanced Nutrition Programme)
Non-surgical skin treatments
(eg anti-wrinkle/dermal fillers/skin tightening treatments etc)

Skincare Details

What would you like to improve about your skin?

What are the main skin issues you would like to address? *

If "other", please specify *

Your current skincare regime

What is your current skincare routine morning and evening? Please name your products if you can.

Have you undergone skin treatments eg chemical peels, laser, anti-wrinkle injections etc?

Are there any particular brands/types of products eg cleansers, retinol, masks etc that you would like advice on in particular?

Do you use sunscreen daily? *

Yes
No

Do you take any skin supplements? *

Yes
No

List them here, or let us know if you'd like advice on skin supplements from the Advanced Nutrition Programme.

If you would like to upload an image so we can advise you further please attach here. Alternatively we can contact you to arrange a face to face consultation if you would prefer.

Please click "Choose file", then select the image from your computer/phone. When you submit your details, the image will also be sent to us.

Do you have any questions about any of our skin treatments?

Non-Surgical Treatments

Please answer as many questions as you can below. If there are no questions below, then please select the "Skincare" option further up the page.

Which non-surgical treatments are you interested in? *

Have you had any non-surgical treatments in the past? *

Yes
No

Please detail what non-surgical treatments you have had *

If you would like to upload an image so we can advise you further please attach here. Alternatively we can contact you to arrange a face to face consultation.

Please click "Choose file", then select the image from your computer/phone. When you submit your details, the image will also be sent to us.

Do you have any other comments or questions?

Medical Information

Please answer as many questions as you can below.

Do you have any medical conditions? *

Yes
No

Please detail your condition(s) below

Are you on any medication? *

Yes
No

Please detail your medication(s) below

Do you have any allergies? *

Yes
No

Please list your allergies below *

Are you pregnant? *

Yes
No

Are you breastfeeding? *

Yes
No

Past Roaccutane treatment? *

Yes
No

Please detail below *

Almost there...

Thank you for taking the time to complete this questionnaire. We hope we can help guide you on your skincare journey.

I confirm that I am over 18 and the above information is accurate *

Yes

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Dublin: +353 1 662 4643

Donegal: +353 74 970 7004

info@fitzgeraldprivateclinic.com

Personal Contact Details*

Skincare

Non-surgical skin treatments

Skincare Details

Your current skincare regime

Non-Surgical Treatments

Medical Information

Almost there...

Personal Contact Details*

Skincare

Non-surgical skin treatments

Skincare Details

Your current skincare regime

Non-Surgical Treatments

Medical Information

Almost there...

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