Get Started | Contact Dermatologist Online

I acknowledge that I am over the age of 18.

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I attest that I am the patient's legal parent or guardian and I permit you to communicate with and evaluate and treat the patient with the BrightDerms platform.

My relationship to the patient:

By submitting this form, you confirm you read, understand, and agree to our Terms and Conditions, Privacy Policy, and Informed Consent.

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Please note, if you are attempting pregnancy, pregnant, or breast-feeding, we strongly encourage an in-person dermatology visit rather than using our platform. Additionally, we cannot prescribe Accutane, Isotretinoin, or any equivalent through BrightDerms.

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I certify that I reside in the State of Florida.

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Personal Information

First name

Last name

Date of Birth

Gender assigned at birth

Are you attempting pregnancy, pregnant, or breast-feeding?

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No

Phone number (numbers and dashes only)

Email address

Home address

Country

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Keep in mind, phone numbers must be 10-digit US phone numbers.

If a field is not applicable, fill in "N/A".

Medical History

Past medical history:

Skin disease history:

Medications:

Allergies:

Do you smoke?

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No

Number of alcohol drinks per week?

Family medical history:

Pharmacy Information

Pharmacy name

Pharmacy address

Country

Pharmacy phone number (numbers and dashes only)

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Keep in mind, phone numbers must be 10-digit US phone numbers.

If a field is not applicable, fill in "N/A".

Which of the following describes your skin condition?

Acne

Rash or spot of concern

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If a field is not applicable, fill in "N/A".

Photo Uploads

Please upload at least 2 photos and at most 3 photos.

Please send photos that are in focus and not blurry, in either .jpg or .png file types.

Photo 1:

Photo 2:

Photo 3:

Please upload a photo of your photo ID.

Photo ID:

Doctor Selection

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You must upload at least 2 photos of your condition and you must upload your photo ID in the photo ID section.

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Personal Information

Medical History

Pharmacy Information

Acne

Rash or spot of concern

Photo Uploads

Doctor Selection