Master All Complaints Teledermatology Submission

Let's get started!

Step 1 of 6
Referrer

Insurance RecoveryTechnical RecoveryRefer Friend EmailEmail SixWEmail ThreeMEmail SixMEmail TwelveMPractice-Mandel_Dermatology-Dr_Mitchell_MandelEmail MLKEmail Feb24 RecoveryPractice-Shiloh_Medical-Dr_Julie_Reilpractice-george_dermatology-mary_georgeoral minoxidilpropecia
Website Start From Location
Physician/Practice Site Referral?
Free Moisturizer
Mail Chimp Email Capture?
California Provider(s) Eligible
Florida Provider(s) Eligible
Email Sender
Current Time

Hour Minutes

AM/PM Option
Current Date*

MonthDayYear
Date
Date with Day

WE'RE SORRY!

Unfortunately you are located in a state that does not allow us to provide remote care for patients.

Please check back soon, as we are actively working on meeting requirements that will allow patient in your state to use DocBright for virtual dermatology care.

WE'RE SORRY!

Unfortunately all of our providers in your state are currently unavailable. This service disruption in your area is temporary, so please check back soon. We apologize for any inconvenience.

If we can be of any help in the meantime, plesae email us at CareTeam@docbright.com

BEFORE YOU BEGIN

Please do not use your browser back or forward buttons during the submission process, as this will erase your data to protect your privacy.

If you need to return to a previous page, please use the "Back" and "Next" buttons at the bottom of each page.

Patient's First Name*
Patient's Last Name*
Patient's Name (OLD)

First NameLast Name
Patient's Email Address*
e.g. name@example.com
Patient's U.S. Cell Phone Number*

PLEASE VERIFY

You entered the patient's email address as:

{patientsEmail}

Please confirm that this is correct before continuing. If the email address is typed incorrectly, it may delay your care.

Patient's Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient's Date of Birth*

MonthDayYear
Date

PLEASE VERIFY

You entered the patient's date of birth as:

{patientsDate} ({patientsAge} years old)

Please confirm that this is correct before continuing. If the date of birth is incorrect, you may have trouble picking up any prescriptions from your pharmacy.

Patient's Age*
Parent Consent Required?
Parent Consent Received?
Phone Call Required?
Are you the minor patient or the minor patient's parent/guardian?*

I am the minor patientI am the minor patient's parent or legal guardian
Since you are a minor, please enter the first and last name of a parent or legal guardian who can give consent for your treatment.*

First NameLast Name
Parent or guardian's email address (they will automatically receive an email notification requesting consent for treatment)*
example@example.com
Patient Gender Assigned at Birth*

MaleFemale
What is the patient's current gender identity? (check all that apply)*

MaleFemaleTransgender Male / Transman / FTMTransgender Female / Transwoman / MTFGender QueerPrefer to Not Answer
Have you submitted on DocBright before?*

Yes - I've made a submission on DocBright before.No - This is my first time using DocBright.
What state is the patient currently located in?*
Phone Call Requirement: Due to telehealth laws and regulations in your state, a phone conversation with your provider is required in order to legally provide you with care.*

I understand that a brief phone conversation with my provider is required before they can legally provide me with care, and I wish to continue with my submission.
Phone Call Availability: Please list at least 3 times that you are available for a phone call from your provider.*
Preferred Call Back Date/Time: 
Second Call Back Date/Time: 
Third Call Back Date/Time:

WE'RE SORRY!

Unfortunately you are located in a state that does not allow us to provide remote care for patients.

Please check back soon, as we are actively working on meeting requirements that will allow patient in your state to use DocBright for virtual dermatology care.

WE'RE SORRY!

Unfortunately all of our providers in your state are currently unavailable. This service disruption in your area is temporary, so please check back soon. We apologize for any inconvenience.

If we can be of any help in the meantime, plesae email us at CareTeam@docbright.com

Provider Control Value

Your caring dermatology provider.

Step 2 of 6
Who previously treated you on DocBright?*
Today's Featured Provider is Dr. Mitchell J. Mandel, M.D., F.A.A.D. Would you like Dr. Mandel to review your submission?*

Yes, I would like Dr. Mitchell J. Mandel, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Nicole Busche-Earley, PA-C Would you like PA Earley to review your submission?*

Yes, I would like Nicole Busche-Earley, PA-C to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Amit Om, M.D. Would you like Dr. Om to review your submission?*

Yes, I would like Dr. Amit Om, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Harib Ezaldein, M.D. Would you like Dr. Ezaldein to review your submission?*

Yes, I would like Dr. Harib Ezaldein, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Anna Chacon, M.D. Would you like Dr. Chacon to review your submission?*

Yes, I would like Dr. Anna Chacon, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Julie Reil, M.D. Would you like Dr. Reil to review your submission?*

Yes, I would like Dr. Julie Reil, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Mary Noel George, M.D. Would you like Dr. George to review your submission?*

Yes, I would like Dr. Mary Noel George, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. William Schaffenburg, M.D. Would you like Dr. Schaffenburg to review your submission?*

Yes, I would like Dr. William Schaffenburg, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Jean-Phillip Okhovat, M.D. Would you like Dr. Okhovat to review your submission?*

Yes, I would like Dr. Jean-Phillip Okhovat, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
Today's Featured Provider is Dr. Kimberly Werner, M.D. Would you like Dr. Werner to review your submission?*

Yes, I would like Dr. Kimberly Werner, M.D. to review my submissionI have no provider preference (your submission will be routed to the next available provider)
There is currently only one California provider available:

Dr. Anna Chacon, M.D.
There are currently only two Florida providers available:

Dr. Anna Chacon, M.D.

Dr. Katherine Nolan, M.D.
Your assigned provider is:

{providersName}
Your assigned provider is:

{providersName}
Provider Acknowledgment*

I acknowledge that the above named provider is assigned to my case and I approve them to provide with medical consultation and treatment.I do not approve the above name provider to review my case.
How would you like us to assign your case?*

Continue with treatment from Dr. Anna Chacon, M.D.I do not approve either provider to review my case
How would you like us to assign your case?*

Continue with treatment from Dr. Anna Chacon, M.D.Continue with treatment from Dr. Katherine Nolan, M.D.I do not approve either provider to review my case
Provider Assigned
Provider's Name
Please share your provider's details*
Please note, your provider is not yet on DocBright. If you choose to continue with your submission, it will be reviewed by the next available provider.*

I understand and wish to continue with my submission.

WE'RE SORRY!

At this time, there is not an alternate provider available to treat you.

If you have any questions, don't hesitate to contact us at CareTeam@docbright.com any time.

A QUICK HEADS UP

PA Nicole Busche-Earley is no longer treating patients via DocBright, but don't worry, we've got you covered!

Your submission will be assigned to Florida-based provider Dr. Anna Chacon, M.D.

Tell us about your preferred pharmacy.

Step 3 of 6
If your treatment plan includes prescriptions, where should we send them?*
In New York, we partner with an online pharmacy, Ravkoo to make it even easier to get your prescriptions for an affordable price. Ravkoo will also deliver your prescriptions to your home same or next day. Would you like to use Ravkoo pharmacy for any prescriptions?

Yes, please send my prescriptions via RavkooNo, I'd like to select my own pharmacy
Please search for, and select your preferred pharmacy. You can search by pharmacy address or name (e.g. "CVS Prince Street New York")*
How do you intend to pay for any prescriptions?*

Cash / No InsuranceUsing my Commercial InsuranceUsing Medicare or Medicaid
Pharmacy Information: Your prescriptions will be sent to Ravkoo, our online pharmacy partner. Ravkoo guarantees the lowest price for your prescriptions regardless of insurance coverage. You will receive a text message from Ravkoo once your prescriptions have been sent confirming their pricing. Once confirmed and paid for, your prescriptions will be delivered to you same or next day!

IMPORTANT PHARMACY INFORMATION

In most cases prescription and/or over-the-counter medications are part of patient treatment plans, although we cannot gaurantee that medications will be ordered or filled from a submission.

Please ensure accurate pharmacy information is entered above. If inaccurate pharmacy information is provided, any prescription(s) will be sent to the pharmacy closest to you for convenience.

Prescriptions sent after-hours, on the weekends, or during holidays may take longer to fill. Please contact your pharmacy directly to ensure that your prescription has been received and processed prior to pickup.

If your pharmacy does not have your prescription on file, ensure they are searching by the patient's date of birth.

Let's learn about the problem you're experiencing today.

Step 4 of 6
Which of the following best describes the problem you are experiencing?*

Hair LossShaving-Related ConcernRashAcneSkin Lesion (Growth)Nail FungusWartWrinkles/AgingSkin IrritationBurnInsect/Animal BiteHyperhydrosis (excessive sweating)Something Else (We treat all conditions of the skin, hair, and nails)
Please note, each DocBright submission is intended to only address a single problem. If multiple issues are submitted that are unrelated, your provider will only be able to address the most prominent or relevant concern.*

I understand and wish to continue with my submission.
Is this a follow-up to a previous submission?*

Yes - I've submitted about this problem on DocBright before.No - This submission is regarding a new or different problem.
Please describe in detail the problem that you are experiencing.*
How long have you been experiencing your current problem*

DaysWeeksMonthsYears
How would you describe your skin?*

DryNormalOilyCombination
How sensitive is your skin?*

1

2

3

4

5

1 is Least Sensitive, 5 is Most Sensitive
What parts of the body are affected? Check all that apply.*

FaceBackNeckChestShouldersArm(s)Leg(s)GroinButtocksGenitalsScalpEarsUnderarmsHandsAbdomenSides/FlanksWaistlineFeetOther
Do you experience any of the following? Check all that apply.*

ItchingPainTendernessWarmthHeatPussBlackheadsWhiteheadsNone of the above applyOther
Is the problem moving, spreading, or changing? Check all that apply*

It's moving/spreadingIt's enlargingIt's bleedingIt's getting darkerIt's getting lighterIt's changing shapeNone of the above applyOther

Help us understand your medical history.

Step 5 of 6
Please check all that apply (or choose none of the above)*

I've had past serious medical illnessesI've had past significant surgeriesI have a significant family medical history to noteI've tried treating my problem before successfullyI consume alcoholI smoke (cigarettes)I have a history of skin cancer(s)I have a family history of skin cancer(s)I've tried treating my problem before unsuccessfullyI've traveled internationally in the last 6-12 monthsI smoke (marijuana)None of the above apply
Please list all past serious medical illnesses you've had.*
Include illness, dates, and outcomes if possible.
Please list all past significant surgeries you've had.*
Include surgery, dates, and outcomes if possible.
Please detail your family's medical history.*
Include details, relationship, dates, and outcomes if possible.
What have you done to previously treat your problem successfully?*
What have you done to previously try treating your problem, but was unsuccessful?*
Do you have any allergies to food or medication?*

YesNo
Please list all food & drug allergies.*
Include the severity and type of reaction for each.
Are you currently taking any medications?*

YesNo
Please list all current medications you are taking.*
Include medication name, dosage, and purpose if possible.
What is your occupation?*
e.g. Carpenter
Do you have any hobbies or activities that you do regularly? Sometimes our daily activities can provide important insight into why we may be experiencing certain symptoms.*

YesNo
Please describe your hobbies or recent daily activities.*
For example, outdoor hiking, woodwork, fishing, boating, car washing, etc.
Are you pregnant or nursing?*

I am currently pregnantI am currently trying to get pregnantI am currently nursingI am not pregnant, trying, or nursing

Let's get your case submitted to your provider!

Step 6 of 6
Is there anything else you would like your provider to know?
How did you first hear about DocBright?*

CosmopolitanBing SearchGoogle SearchFacebookYouTubeInstagramDoctor's OfficeFriend / Relative / Word of MouthRedditOther
If you didn't get virtual care from DocBright, how would you have sought out treatment?*

In-Person DermatologistIn-Person Primary CareHospital/ERAnother Telehealth PlatformI would have waited until my next doctor's appointmentI would have waited to see if it improved on its ownOther
Photo Uploads

UPLOAD NOW OR LATER

If you'd like to upload photos later, you will automatically receive a unique photo upload link via email. You can use this link to easily submit your photos later from a different device, such as an iPhone or Android.

Please keep in mind that your submission will remain as pending until all required photos have been uploaded.

Please upload 1-3 photos of your problem (the more the better), ensuring they are taken from varying distances and that the problem is in clear focus with ample lighting.

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Please upload a photo of the front of the patient's photo ID. A photo ID is required to confirm the patient's identity. Without a photo ID, our providers are not legally able to provide their patients with care.

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This may be a driver's license, passport, or other card. Please do not upload condition photos in this field. They should only be uploaded in the previous step. If you do not have your photo ID available at this time, you may submit it later.
Cancelof
Provider Consent
Provider's Cell for SMS Notification
old Provider's Cell for SMS Notification
Please enter a valid phone number.
Your assigned provider is:

{providersName}
Open Response Link
Acne Response Link
Rash Response Link
Onychomycosis Response Link
In-Person Care Response Link (Lesion)
Request Info Link
Your Name (parent or guardian who is reviewing the above acknowledgments and signing below)*

First NameLast Name
Please upload a picture of your photo ID

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If you are having upload issues, please send the photo ID to submissions@docbright.com and submit this form without the upload.
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By signing below (draw in box using finger or mouse), I attest that I am the patient's parent or legal guardian. Additionally, by signing below, I attest that I have read, understand, and agree to the patient's assigned provider's legal notices including (but not limited to) Notice of Privacy Practices (NPP) and Informed Consent. Finally, I consent to allowing the patient's provider to communicate with and treat the patient via the DocBright platform and its associated tools.*

Clear
Submitted a Photo ID?
Submitted Condition Photos?

IT'S THE WEEKEND!

You are submitting your case on, or near a weekend. While most cases are still answered within 24 hours on weekends, you may not receive your response until the next business day.

Should be Empty:

Let's get started!

Your caring dermatology provider.

Tell us about your preferred pharmacy.

Let's learn about the problem you're experiencing today.

Help us understand your medical history.

Let's get your case submitted to your provider!

Photo Uploads

Provider Consent