DermOnDemand

1
Who needs help today?* This field is required.
Myself
Dependent
2
What is your name?* This field is required.
First Name
Last Name
3
What is their name?* This field is required.
First Name
Last Name
4
What is your email?* This field is required.
example@example.com
5
What is your cell phone number?* This field is required.So we can text you when the diagnosis and treatment plan is ready
Please enter a valid phone number.
6
What can we help you with today?* This field is required.
Acne
Hyperpigmentation / Melasma
Hair Loss / Hair Thinning
Dandruff
Eczema
Rosacea
Psoriasis
Rash
Cold Sore
Nail/Feet
Anti-Aging
Not Sure
Other
7
When did this concern start?* This field is required.
Less than a week
1 Month
6+ Months
1 Year +
8
Has this concern occurred before?* This field is required.
YESNO
9
List any past treatments you've tried and whether they worked * This field is required.
10
Do you have any of these symptoms?* This field is required.You can choose more than 1 option
Burning
Itching
Pain
Tingling
Bleeding
Fever
Nausea/Vomiting/Diarrhea
None of the above
Other
11
Please select location(s) where the skin concern is occurring* This field is required.
Scalp
Face
Neck
Chest/Abdomen
Back
Arms
Legs
Feet
Hands
Nails
Other
12
Do you have any additional details to share?
13
Photos of skin or hair loss concern* This field is required.Provide a minimum of 2 clear images (near and far) with good lighting, (no blurry photos, please!). Share images of all areas that are affected. If you have concerns on your face, please provide an additional full face image as well.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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14
Any history of medical conditions?* This field is required.Examples: Diabetes, Asthma, Hypertension, Cancer
YESNO
15
Please select which medical condition(s)* This field is required.Select all the apply
Diabetes
Hypertension
Cancer
Asthma
Autoimmune
Other
16
Please specify the autoimmune condition* This field is required.
17
Currently taking any medications?* This field is required.Please consider prescriptions and non-prescriptions
YESNO
18
Please list medications* This field is required.
19
Allergic to any medication(s) or food?* This field is required.Examples: Penicillin, Aspirin, Bactrim
YESNO
20
Please list the medication(s) allergic to* This field is required.
21
Date of birth* This field is required.
Month
Day
Year
22
Gender* This field is required.
MaleFemale
23
Pregnant?* This field is required.
Yes
No
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Pharmacy Information* This field is required.
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address
25
Your Address* This field is required. So the pharmacy can identify you
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Belgium
Belize
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Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
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Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
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Tunisia
Turkey
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Turks and Caicos Islands
Tuvalu
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Ukraine
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Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
26
DermOnDemand* This field is required.24 hours to get your diagnosis and treatment plan. Cost of medications not included (commonly covered by insurance).
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ORDER SUMMARY
Total costUSD
Dermatology Visit (for Hair Loss / Hair Thinning)
Our annual hair care program provides a year of personalized treatment for hair loss or thinning. We’ll prescribe a customized plan for you with medications sent directly to your pharmacy and may suggest over-the-counter options to enhance results.
$200.00Edit
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Annual Coverage for Accutane (Severe Acne)
Our annual Accutane program provides a year of personalized treatment for your acne care.
$500.00Edit
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Annual Coverage for Acne (Mild & Moderate)
Our annual acne program provides a year of personalized treatment for mild to moderate acne care. We’ll prescribe a customized plan for you with medications sent directly to your pharmacy and may suggest over-the-counter options to enhance results.
$200.00Edit
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Dermatology Visit (Covers Acute Issues)
Remote visit for immediate relief from itches or rashes. (In some cases if we diagnose you with a chronic condition, we will suggest that you change to an annual coverage plan).
$95.00Edit
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1
1
Quantity
Subtotal: $0.00
Dermatology Visit (for Anti-Aging)
Our annual anti-aging program provides a year of personalized treatment for anti-aging of your skin. We’ll prescribe a customized plan for you with medications sent directly to your pharmacy and may suggest over-the-counter options to enhance results.
$200.00Edit
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Total cost $0.00
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Weight (in lbs)* This field is required.
28
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