Written photo review

Patient intake form

Please complete the details below by checking the correct boxes and filling in the brief answers. Add clear photos of the concern — Dr. Imam will reply in writing within 48 hours.

Patient Name

Date of Birth

Your written review will be sent here.

Phone

Optional — WhatsApp number preferred.

1. Main Skin, Mouth, or Hair Concern

Where on your body is the problem located?

When did this issue first start?

How has it changed over time?

Getting betterGetting worseComes and goes

2. Symptoms Checklist

Check all that apply.

Painful sores or blisters inside the mouthConstant dry mouth or dry eyesSkin rash, redness, or bumpsSevere itching or burning feelingHair loss or changes in your nailsStiff or aching joints (especially in the morning)Feeling unusually tired or having a feverUnplanned weight loss

3. Triggers & Past Treatments

Does sunlight make the problem worse?

YesNoNot sure

Known skin allergies or reactions to products/materials

Creams, ointments, or medicines you have already tried

4. Medical & Family Background

Have you been diagnosed with any immune system or long-term skin conditions?

YesNo

Does anyone in your family have a history of skin disorders or immune conditions?

YesNo

5. Photos of the Concern

Upload 1–3 clear, well-lit photos (JPG, PNG, or WebP — max 5MB each). Include one close-up and one from a normal distance.

I understand a photo review has limits: photos cannot show warmth, texture, or what a lesion feels like, and this is not a substitute for an in-person or video examination. If my symptoms are severe or urgent, I will seek immediate care instead.

Written response within 48 hours · Payment details follow by email