Master All Complaints Teledermatology Submission

First Name Last Name

e.g. name@example.com

Street Address

Street Address Line 2

City State

Zip Code

I am the minor patient I am the minor patient's parent or legal guardian

First Name Last Name

Male Female Transgender Male / Transman / FTM Transgender Female / Transwoman / MTF Gender Queer Prefer to Not Answer

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 us to consult with patients in your state. We apologize for any inconvenience.

Yes, I would like Dr. Mitchell J. Mandel, M.D. to review my submission I have no provider preference (your submission will be routed to the next available provider) I would like my submission to be reviewed by a specific provider (you will provide their name in the next step)

Yes, I would like Nicole Busche-Earley, PA-C to review my submission I have no provider preference (your submission will be routed to the next available provider)

Yes, I would like Dr. Amit Om, M.D. to review my submission I have no provider preference (your submission will be routed to the next available provider)

Yes, I would like Dr. Harib Ezaldein, M.D. to review my submission I have no provider preference (your submission will be routed to the next available provider)

Did you enter accurate information for a pharmacy near you? If innaccurate pharmacy information is provided above, any prescriptions will be sent to the pharmacy closest to you.

Cash / No Insurance Using my Commercial Insurance Using Medicare or Medicaid

Please keep in mind that prescriptions sent after hours, on weekends, or during holidays may take longer to fill. Always contact your pharmacy prior to pick-up to ensure that it has been filled and is ready for pick up.

I understand and wish to continue with my submission.

Yes - I've made a submission on DocBright before. No - This is my first time using DocBright.

Yes - I've submitted about this problem on DocBright before. No - This submission is regarding a new or different problem.

Include illness, dates, and outcomes if possible.

Include surgery, dates, and outcomes if possible.

Include details, relationship, dates, and outcomes if possible.

Include the severity and type of reaction for each.

Include medication name, dosage, and purpose if possible.

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

Days Weeks Months Years

Dry Normal Oily Combination

1 is Least Sensitive, 5 is Most Sensitive

It's moving/spreading It's enlarging It's bleeding It's getting darker It's getting lighter It's changing shape None of the above apply Other

Google Search Bing Search Facebook Instagram Doctor's Office Friend / Relative / Word of Mouth Cosmopolitan Other

Photos should be take from varying angles and distances. Ensue all photos are clear and in focus, and that the problem is clearly visible in even light. *Note: if you are having trouble submitting your form with photos, please remove the photos, resubmit your form, and email the photos to submissions@docbright.com. They will then be attached to your submission.

This may be a driver's license, passport, or other card. *Note: if you are having trouble submitting your document, please remove the file, resubmit your form, and email the document to submissions@docbright.com. It will then be attached to your submission.

Your assigned provider is:

{providersName}

First Name Last Name

If you are having upload issues, please send the photo ID to submissions@docbright.com submit this form without the upload.

Professional Fee

$ 30.00

Technology Fee

$ 19.00

Enter coupon

Total

$ 0.00

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Unless you would like to use your existing PayPal account for checkout, choose the "Debit or Credit Card" option below.

If you've experienced technical issues with your submission, please use a Google Chrome Incognito window and do not upload any attachments. After submission, send your photos and attachments to submissions@docbright.com.

Patient Registration

Choose Your Provider & Pharmacy

Initial Assessment

General Assessment

Final Step

Photo Uploads

Provider & Consent

Pay & Submit