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Pure Obagi

Contacting our partners at Skinstation

To enable Skinstation’s trained physicians to provide you with advice on the full range of Obagi products, it will be necessary for you to complete their form below. Following this they will contact you to arrange a telephone consultation with a member of their Medical Team. This will help ensure that you are provided with the appropriate products and that you achieve the best possible clinical results for your skin type. Please note that all consultations are conducted in English language.

Name *

First

Last

Email *

Contact number *

Date of Birth *

DD/MM/YY

Please confirm that you are over 12 years of age by ticking this box *

I confirm

Please choose your skin type from the list below *

Pale white skin, blue/hazel eyes, blond/red hair (Always burns, does not tan)
Fair skin, blue eyes (Burns easily, sometimes tans)
Darker white/medium skin (Sometimes burns, always tans)
Light brown skin (Burns minimally, tans easily)
Brown skin (Rarely burns, always tans)
Dark brown or black skin (Never burns, always tans dark)

Do you currently have or have you ever suffered from any of the following medical conditions? *

Diabetes
High blood pressure
Ocular pressure problems
Hormone imbalance
Cold sores
Skin disease/skin lesions
Pigmentation abnormalities
Keloid scarring
Any active infection
Any allergies

Any other medical conditions?

Are you currently taking any medication? If so, what is the medication and what are you taking it for? *

Please confirm that you are not pregnant, breastfeeding or planning on getting pregnant *

I confirm

Please confirm that these items are for your own personal use *

I confirm

I choose to waive the option of a face-to-face consultation and confirm that all of the information provided is true and correct *

I confirm

Do you have any other health issues that we should be aware of? *

No
yes

If yes, please give details of other health issues we should be aware of:

Please give us a small description of your skin issues and what you are looking to achieve: *

Would you like to upload a picture of your skin to help us better assess you? and if you could give us a small description of what skin issues you would like to address.

Click or drag a file to this area to upload.

Contact

Pure Obagi
Ground Floor,
Unit C16, The Exchange, Calmount Business Park, Ballymount,
Dublin 12,
D12 RF43,
Ireland

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