Dermadry Prescriptions

We need to ask for weight and height of people below 19 years old.

Weight (lbs)

Height (cm)

Note: Please be advised that verifying patient ID is a mandatory requirement for all doctor’s appointments, whether they are conducted in-person or via telemedicine. Thank you for your cooperation!

ID Picture

Use a screenshot or small file (under 2MB)

Upload a government-issued photo ID that displays your legal name and date of birth for patient verification purposes. (image in png or jpeg format)

Your identity card is kept secure and confidential. It will only be used for verification purposes and will not be shared with unauthorized parties.

Here’s your first message to your doctor. Please introduce yourself and feel free to:

Ask any questions you have
List any medical problem you have which were not discussed above
Include anything else you would like the doctor to know.

Since you are a minor, we need parental/guardian consent before continuing further.

Parent or guardian’s first name

Parent or guardian’s last name

Parent or guardian’s date of birth

I confirm that I, [] [] am the parent/legal guardian of [] [] do hereby give my consent for a telemedicine consultation regarding hyperhidrosis and considering treatment with Dermadry

To confirm your identity as [] [], please upload a photo of yourself holding your ID.

Picture

Choose picture

Please acknowledge that you understand and agree to the following:

I have consented to being provided care via telemedicine and filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me.
I understand all the questions that have been asked of me.
The information that I have provided is accurate and complete.
I am the patient who is consenting to be evaluated for treatment.

I acknowledge and agree to the above

I do not acknowledge and agree to the above

Telemedicine Consultation Form