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Case Report Application Form
Case Report Application Form
Recommendations:
High-resolution pictures (i.e 300ppi) taken with professional camera
Max total file size: 25MB
Before and After pictures shall be taken from the same angle
White background is highly recommended
Make-up and accessories should be avoided
Photo without filters
General information
Choose category:
Rejuvenation (face, hands and decolletage)
Hair loss
Melasma
Acne
Slim face & Body shaping
Used Products:
*
Information about the patient
Patient age:
*
Patient sex:
*
Man
Woman
Area, pathology:
*
Type of treatment:
*
Average volume/frequency/sessions:
*
Daily home care:
*
Combination treatment
*
Result evaluation:
Comments:
Pictures
Before (Upload image)
*
Drop files here or
Select files
Max. file size: 2 GB, Max. files: 3.
Maximum 3 Files
After (Upload image)
*
Drop files here or
Select files
Max. file size: 25 MB, Max. files: 3.
Maximum 3 Files
How many days after the result picture(s) is/are taken?
*
Additional images
Drop files here or
Select files
Max. file size: 25 MB, Max. files: 6.
Maximum 6 Files
Information about the doctor
Photo
*
Max. file size: 25 MB.
Name:
*
Surname:
*
Email
*
Country:
*
Select country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Speciality:
*
Patient's consent for the use of its personal data
Hereby I, Dr.
...
, grant to Skin Tech Pharma Group SL, the permission to take and use the submitted information of my patient including photography and/or any other visual material for its marketing purpose such as News release, Social Network marketing and/or for its educational materials. These materials might include printed or electronic publications, Web sites or other electronic communications.
I grant also that every image transferred through this submission form is obtained and delivered according to the legislative prescriptions and regulations of the country. I authorize the use of these images without compensation to me and/or to my patient, owing to my previous written agreement with my patient. All negatives, prints, digital reproductions shall be the property of Skin Tech Pharma Group SL.
It is granted by Skin Tech Pharma Group SL, the access and rights to the signing part conferred by the Spanish Law on the Protection of Personal Data (2016/679).
Accept conditions
*
I have read and accept the conditions
Consent patient protection image rights
*
Max. file size: 2 GB.
Please download, fill, sign and upload the following file:
Consent patient protection image rights file
Accept privacy policy
*
I accept the
Privacy Policy
Accept third parties
I expressly consent that Skin Tech Pharma Group SL may transfer freely my data to third parties (local distributos of my area) with whom an agreement is signed for the protection of my data, solely for using it in the same purpose of Skin Tech Pharma Group SL.
These third parties can be located in countries which:
*
Have an equivalent level of data protection subjected to the EU regulation 2016/679.
Have a minor level of data protection compared to aforementioned regulation.
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