Teledermatology Form for New Patients or Established Patients with New Problems.

This Teledermatology Form will enable you to contact me for a specific question. It is a good way to answer most consultations. Please be aware that it is not encrypted and is not HIPAA compliant. This is a free service. If you are worried about someone hacking this, don't use it. If you want help with a problem, we are here to serve. Everything here is confidential. It is between you and me and it won't be shared it with anyone unless you specifically ask me to do so.

First Name: *

Last Name *

Age: *

Male

Female

Transgender

Please enter your email address twice. *

Email *

What questions do you have for me? *

History: Please describe your problem as best you can. Your narrative should include your concerns, diagnoses you, your friends or other doctors have suggested, interventions, outcomes, how long you’ve had this. Please describe your medical history and include family illnesses that you think could be related to your condition. *

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Please list all medications do you take or use. This includes, oral, injectable and topically applied. *

Do you have any known allergies? If yes, please list them and the type of reaction you have had. *

Do you have any other medical problems? If so, please list. *

Describe your skin problem as best you can? *

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Clinical Images are important. These are best taken in indirect natural (outdoors if possible) light. They will not be placed on any accessible web site. If you wish specific guidelines for clinical photography, please go to this link: Clinical Photography. JPG is the best format. Large files take a long time to download, so please limit size of each photo to ~ 300K.

Clinical Pictures

What do you think is going on? *

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What questions do you have for me? *

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What pharmacy do you use and its telephone number?

If I listen to you long enough, you may be telling me what the diagnosis is!

Thank you. I hope this is helpful!. If you do not get an email back with a reasonable amount of time, please call my office at 413-458-2800 or email me at DJE.

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