To purchase Prescription strength or select SkinCeuticals products, please complete the form below:

PLEASE NOTE: Our staff will contact you at the phone number listed below within 24 hours to confirm your order and collect payment. Prescription strength products are available ONLY to established patients who have been seen by a medical provider at Audubon Dermatology within the last year.

Product Request Form

FULL NAME

DATE OF BIRTH

PHONE NUMBER

EMAIL ADDRESS

MAILING ADDRESS

PLEASE SELECT DESIRED PRESCRIPTION STRENGTH PRODUCT(S) BELOW (prices do not include sales tax) PLEASE SELECT DESIRED PRESCRIPTION STRENGTH PRODUCT(S) BELOW (prices do not include sales tax) Audubon Dermatology Brightening Pads with Hydroquinone 4% -$101.00 Audubon Dermatology Brightening Pads with Hydroquinone 6% - $117.00 Audubon Dermatology Brightening Pads with Hydroquinone 8% - $133.00 Latisse 5mL - $207.52 Obagi Nu-Derm Clear 4% - $130.00 Tretinoin Gel 0.01% - $47.00 Tretinoin Gel 0.025% - $52.00 Tretinoin Gel 0.05% -$57.00 Tretinoin Gel 0.1% -$62.00 Upneeq Eyedrops - $200.00

PLEASE SELECT DESIRED SKINCEUTICALS PRODUCT(S) BELOW (prices do not include sales tax) PLEASE SELECT DESIRED SKINCEUTICALS PRODUCT(S) BELOW (prices do not include sales tax) SkinCeuticals Blemish + Age Defense Serum - $106.00 SkinCeuticals C E Ferulic - $182 SkinCeuticals Daily Brightening UV Defense Sunscreen SPF 30 - $60.00 SkinCeuticals Discoloration Defense - $108.00 SkinCeuticals H.A. Intensifier - $110.00 SkinCeuticals LHA Cleansing Gel - $42.00 SkinCeuticals Metacell Renewall B3 - $126.00 SkinCeuticals Phloretin CF Gel - $182.00 SkinCeuticals Phyto A+ Brightening Treatment - $110.00 SkinCeuticals Phyto Corrective Essence Mist - $69.00 SkinCeuticals Phyto Corrective Mask - $66.00 SkinCeuticals Resveratrol BE - $168.00 SkinCeuticals Triple Lipid Restore 2:4:2 - $150.00

PLEASE SELECT PREFERRED PAYMENT TYPE

HOW WOULD YOU LIKE TO RECEIVE YOUR ORDER?

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LOCATION:

3525 Prytania Street, Suite 501, New Orleans, LA 70115

LOCATION:

3525 Prytania Street, Suite 501, New Orleans, LA 70115

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504-895-3376

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