Dermagrid Scan Upload

1
Professional User* This field is required.
First Name
Last Name
2
Professional Email* This field is required.
example@example.com
3
Client Name* This field is required.
First Name
Last Name
4
Client Age* This field is required.
5
Image Area* This field is required.
Face
Hand
6
Report Type* This field is required.Please indicate the type of report(s) you would like to generate.
Basic Report
Basic + Pro Report (charges will apply)
7
Upload Image* This field is required.Please ensure the image quality prior to uploading by checking the following standards: 1) Image Clarity [not blurry] 2) Correct Defined Area 3) Correct Distance [not too close or far away]
Drag and drop files here
Select files to upload
Cancelof
8
User Agreement* This field is required.Please review Terms and Conditions and Policies and Procedures of Dermagrid by clicking the links.
I, the subscriber, agree to the terms and conditions and policies and procedures of DermaGRID.
9
Signature
Clear
Should be Empty: