Dr. Pimm's Customer Intake Form
Hello, Dr. Pimm here! There are a few things I need from you before I can send you a cream. This form will allow me to determine what exactly is going on with your skin as some of you might have skin conditions that are not eczema. With the following information, we can find the best solution to your skin issues together. After you submit the form, you'll be redirected to the consultation booking page.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Sex
Please Select
Male
Female
AMAB
AFAB
Other
Date of Birth
*
-
Month
-
Day
Year
Date
Weight (kg)
Please enter your weight in kilograms.
Height (cm)
Please enter your height in centimeters.
Please list any medications you are currently taking with dates of use if known:
*
Do you have any allergies?
*
What is your current skincare routine?
Okay, what seems to be the problem? Please describe the affected area(s).
*
Please upload clear, well-lit images of the affected area(s).
*
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