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Patient details

Patient full nameEmailPhone

Date of birth

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PPS number (optional)

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IE · Eczema · Full

This form is for ongoing eczema (atopic dermatitis) that hasn't recently changed in character. Please upload a clear photo of the affected area — this is required for the doctor to assess severity, distribution, and check for signs of infection. If your answers suggest a skin infection, widespread flare, or a possible emergency, you may be directed to urgent care or a video consultation rather than treated through this form.

About your eczema

Please upload a clear photo of the affected area (more than one area if applicable)

How long have you had this flare?

Roughly how much of your body is affected?

How severe is the flare?

Do you have any of the following right now? (select all that apply)

Have you developed painful, fluid-filled blisters or punched-out-looking sores, especially if spreading quickly or with fever?

Which part of the body is affected? (select all that apply)

Face or eyelidsGenital area or skin folds (armpits, groin, under breasts)Body, arms, or legsScalp

What are you currently using for this, and how often? (emollient name/frequency, steroid name/strength if known, any calcineurin inhibitor)

If you're using a topical steroid, how many weeks have you been using it continuously?

Have you already tried a potent steroid for this flare without it improving?

Have you needed two or more courses of antibiotics for infected eczema in this area recently?

Your health

Are you pregnant or breastfeeding?

Any known allergy or reaction to a specific steroid cream, emollient, or ingredient (e.g. lanolin)?Write "None" if you have none.

Patient address

Required for medical documents and any physical materials.

Street addressApt / unit (optional)CityEircode (optional)

Data sharing consent (GDPR)

I confirm the details above are accurate and consent to a video consultation with the selected clinician.I consent to my personal and medical data being processed by Global Health and shared with its treating clinics and medical network — including clinics in other countries — for the purpose of my care, service improvement, and security. Privacy PolicySend me appointment updates via WhatsApp (optional)

Eczema Treatment

Eczema Treatment

About your eczema

Your health