Skin Condition Photo Intake Form
Submit your skin concern photo and provide essential details for a thorough review. Please complete all sections of the Skin Condition Photo Intake Form.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Upload Photo of Skin Concern
*
Upload a File
Drag and drop files here
Choose a file
Cancel
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Where is the skin concern located?
*
Please Select
Face
Scalp
Neck
Chest
Back
Arms
Hands
Legs
Feet
Other
How long have you had this skin concern?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Describe the symptoms (select all that apply)
*
Redness
Itching
Pain
Blistering
Scaling
Swelling
Discoloration
Other
Have you tried any treatments?
*
No
Yes, over-the-counter
Yes, prescription
Other
Do you have any relevant medical conditions?
None
Eczema
Psoriasis
Allergies
Diabetes
Other
What is your age group?
*
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
How would you describe your skin type?
Oily
Dry
Combination
Sensitive
Normal
Please provide any additional details about your skin concern
Submit
Should be Empty: