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Photos At Home By Dr. Semaan
Hi there, please fill out and submit your photos with this form.
6
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1
How to take photos from home:
Time to take the photos. Once Dr Steve and Dr Amesha have 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 lenght of treatment required later in life. Press next once completed
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2
Patient Name
*
This field is required.
First Name
Last Name
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3
Date of Birth
*
This field is required.
Date
Day
Month
Year
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4
Current date
Date
Day
Month
Year
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5
Age
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6
Responsible Party
First Name
Last Name
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7
Relationship to patient
Mother
Father
Grandparent
Other
Mother
Father
Grandparent
Other
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8
Email
*
This field is required.
example@example.com
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9
Mobile Number
*
This field is required.
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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
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11
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