You can always press Enter⏎ to continue
Photos At Home By Dr. Semaan
Hi there, please fill out and submit your photos with this form.
6
Questions
START
1
How to take photos from home:
Time to take the photos. Once Dr Steve has reviewed the photos, we will be able to advise you of the next steps. By sending these photos you can help prevent more invasive treatment or reduce the length of treatment required later in life. Press Next once completed
Previous
Next
Submit
Press
Enter
2
Patient Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
Date of Birth
*
This field is required.
/
Date
Day
Month
Year
Previous
Next
Submit
Press
Enter
4
Current date
/
Date
Day
Month
Year
Previous
Next
Submit
Press
Enter
5
Age
Previous
Next
Submit
Press
Enter
6
Responsible Party
First Name
Last Name
Previous
Next
Submit
Press
Enter
7
Relationship to patient
Mother
Father
Grandparent
Other
Mother
Father
Grandparent
Other
Previous
Next
Submit
Press
Enter
8
Email
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
9
Mobile Number
*
This field is required.
Previous
Next
Submit
Press
Enter
10
Upload photos
*
This field is required.
A minimum of 6 photos are required
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
10
See All
Go Back
Submit
