Dermatology Telehealth Medical Examination Form
Patient Name
First Name
Last Name
Guardian Name - if the patient is younger than the age of 18.
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Photo Upload
Please be careful that uploaded photos are clear.
Photo Upload 1 - Close Up Photo of Your Condition
Browse Files
Cancel
of
Photo Upload 2 - Far Photo of Your Condition
Browse Files
Cancel
of
Please state the details of your condition
I authorize the Health Care Service to provide a dermatology consultation and agree to pay that one-time consultation fee.
Yes
No
Patient Signature
My Products
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Teledermatology Consultation
$80.00
$
80.00
Total
$0.00
$
0.00
Credit Card
Submit
Should be Empty: