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Your Name*

Your Phone Number*

Your Email Address*

Your residence*

What is your ethnicity?*

How long have you suffered from pigmentation?*

Please upload up to FOUR high quality photographs in order for our clinical team to triage your condition.*

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Accepted file types: jpg, gif, png, pdf, heic, jpeg, Max. file size: 128 MB, Max. files: 4.

Photos & clinical information is treated with the utmost confidentiality.

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