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Garden State Dermatology Virtual Form

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Virtual Consultation Form

PROBLEM DETAILS

Skin Condition :
Symptoms :
How long have you had the condition(days)?
Was it treated by a physician?
No
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Yes
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If YES what medicine was prescribed?
Was it biopsied before?
No
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Yes
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Do you have any medical allergies?
No
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Yes
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If YES please list them below :