Before & After Submission

Before & After Photo Submission

This submission form is for ONE patient. You can submit multiple photos for each patient, but you MUST complete a separate form for each.
Your Name

First NameLast Name
E-mail
example@example.com
Business Name
Business Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PATIENT INFORMATION
Patient Name

First NameLast Name
Age, Sex, and Basic Demographic
Fitzpatrick
Skin Concern
pigment, fine lines, scars, texture, etc.
Product Used
Number of treatments / how often / did you combine with other treatments?
(e.g.): 4 weekly treatments of PRX Derm Perfexion combined with microneedling on week 3
Photo & Video Release Form

A photo & video release must be signed by the patient. Please email or text your patient the link below

PHOTO & VIDEO RELEASE FORM
Upload Photo/s

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Before & After Photo Submission