Teledermatology Referral Research Form
A signed Photographic Consent Form is required for study enrollment
Referring Provider
Date of Referral
Email
Patient ID Number:
Case Summary
Differential Dx
Current Management Plan (excluding digital dermatology consult)
Treatment
Tests
Follow-up
Triage Method
Consultation Time Factor
Normal
Urgent
STAT!
Rules
Grand Rounds
Expert Match
Alaska
VAMC
A Specific Dermatologist
Location of Digital Images (please specify the uniform resource location (URL). JPEG images are preferred, up to 300 KB in size, with a preferred dimensions of 400 x 600 pixels.
Image Security Information
User Name
Password
Click
to submit your case. Click
to clear your message and start over.
This document is a resource
from the
Internet Dermatology Society
Send your comments to:
Rhett Drugge, M.D.
Last update: September 21, 1995
