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| <_form id="userform__form_2584" action="/contact-us/submit-a-photo/_form" method="post" enctype="multipart/_form-data" class="userform" data-toperrors="data-toperrors"> | | <div class="container-contact"> |
| <p id="userform__form_2584_error" class="message " aria-hidden="true" style="display: none;"></p> | | <_form action="email" recaptcha-v3-action="filedonationform"> |
| | <_email template="MediaWiki:FlexForm_filedonation_template"></_email> |
| <div class="userform-fields"> | | <div class="userform-fields"> |
| <div id="Editable_formStep_00d79" class="_form-step field CompositeField userformsstep" data-title="First Page">
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| <div class="error-container" aria-hidden="true" style="display: none;"><div><h4></h4><ul class="error-list"></ul></div></div>
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| <div id="userform__form_2584_EditableTextField_6debd_Holder" class="userdefinedthing field _input-wrap _input-wrap--text text">
| | <_label for="name">Your name (full name or company)</_label> |
| <_label class="left" for="userform__form_2584_EditableTextField_6debd">Your name (full legal/company)</_label> | | <_input type="text" id="name" name="name" required="required" placeholder="Your name.."/> |
| <_input type="text" name="EditableTextField_6debd" class="text" id="userform__form_2584_EditableTextField_6debd"/> | |
| </div>
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| <div id="userform__form_2584_EditableTextField_f6b88_Holder" class="userdefinedthing field _input-wrap _input-wrap--email text email text">
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| <_label class="left" for="userform__form_2584_EditableTextField_f6b88">Email</_label>
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| <_input type="email" name="EditableTextField_f6b88" class="email text" id="userform__form_2584_EditableTextField_f6b88" required="required" aria-required="true" data-rule-email="data-rule-email"/>
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| </div>
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| <div id="userform__form_2584_EditableTextField_da2bf_Holder" class="userdefinedthing field _input-wrap _input-wrap--text text">
| | <_label for="email">Email</_label> |
| <_label class="left" for="userform__form_2584_EditableTextField_da2bf">Address (include country) </_label> | | <_input type="text" id="email" name="email" required="required" placeholder="Your email.."/> |
| <_input type="text" name="EditableTextField_da2bf" class="text" id="userform__form_2584_EditableTextField_da2bf"/> | |
| </div>
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| <div id="userform__form_2584_EditableTextField_47c87_Holder" class="userdefinedthing field _input-wrap _input-wrap--dropdown dropdown"> | | <_label for="address">Address (include country)</_label> |
| <_label class="left" for="userform__form_2584_EditableTextField_47c87">Tell us your profession or specialty</_label> | | <_input type="text" id="address" name="address" required="required" placeholder="Your address.."/> |
| <_select name="EditableTextField_47c87" class="dropdown" id="userform__form_2584_EditableTextField_47c87" > | | |
| <_input type="option" value="Please _select">Please _select</_input> | | <_label class="left" for="specialty">Tell us your profession or specialty</_label> |
| <_input type="option" value="Dermatology" _selected="_selected">Dermatology</_input> | | <_select name="specialty" class="dropdown" id="specialty" > |
| <_input type="option" value="Primary Care Physician">Primary Care Physician</_input> | | <_input type="option" value="Please select">Please select</_input> |
| <_input type="option" value="Marketing/media">Marketing/media</_input> | | <_input type="option" value="General Practice" selected="_selected">General Practice</_input> |
| | <_input type="option" value="Musculoskeletal Medicine">Musculoskeletal Medicine</_input> |
| | <_input type="option" value="Allied Health">Allied Health</_input> |
| <_input type="option" value="Other health professional">Other health professional</_input> | | <_input type="option" value="Other health professional">Other health professional</_input> |
| <_input type="option" value="Other (not a health professional)">Other (not a health professional)</_input> | | <_input type="option" value="Other (not a health professional)">Other (not a health professional)</_input> |
| <_input type="option" value="Medical student or physician in training">Medical student or physician in training</_input> | | <_input type="option" value="Medical student or doctor in training">Medical student or doctor in training</_input> |
| <_input type="option" value="Patient or caregiver">Patient or caregiver</_input> | | <_input type="option" value="Patient or caregiver">Patient or caregiver</_input> |
| </_select></div> | | </_select> |
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| <div id="userform__form_2584_EditableTextField_f7377_Holder" class="userdefinedthing field _input-wrap _input-wrap--textarea textarea">
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| <_label class="left" for="userform__form_2584_EditableTextField_f7377">Image diagnosis/caption</_label>
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| <textarea name="EditableTextField_f7377" class="textarea" id="userform__form_2584_EditableTextField_f7377" rows="5" cols="20"></textarea>
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| </div>
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| <div id="userform__form_2584_Image1_Holder" class="userdefinedthing field _input-wrap _input-wrap--file file">
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| <_label class="left" for="userform__form_2584_Image1">Upload photo(s)</_label>
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| <div class="file-drop-area">
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| <span class="fake-btn">Choose file</span>
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| <span class="file-msg js-set-number">or drag and drop a file here</span>
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| <_input type="hidden" name="MAX_FILE_SIZE" value="5242880000"/>
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| <_input class="file-_input" accept=".ace,application/x-ace-compressed,.arc,application/x-freearc,.arj,.asf,video/x-ms-asf,.au,audio/basic,.avi,video/x-msvideo,.bmp,image/bmp,.bz2,application/x-bzip2,.cab,application/vnd.ms-cab-compressed,.cda,.csv,text/plain,.dmg,application/x-apple-diskimage,.doc,application/msword,.docx,application/vnd.openxml_formats-officedocument.wordprocessingml.document,.dotx,application/vnd.openxml_formats-officedocument.wordprocessingml.template,.flv,video/x-flv,.gif,image/gif,.gpx,application/gpx+xml,.gz,application/gzip,.hqx,application/mac-binhex40,.ico,image/x-icon,.jpeg,image/jpeg,.jpg,.kml,application/vnd.google-earth.kml+xml,.m4a,.m4v,video/x-m4v,.mid,audio/midi,.midi,.mkv,video/x-matroska,.mov,video/quicktime,.mp3,audio/mpeg,.mp4,video/mp4,.mpa,.mpeg,video/mpeg,.mpg,.ogg,audio/ogg,.ogv,video/ogg,.pages,.pcx,image/x-pcx,.pdf,application/pdf,.png,image/png,.pps,application/vnd.ms-powerpoint,.ppt,.pptx,application/vnd.openxml_formats-officedocument.presentationml.presentation,.potx,application/vnd.openxml_formats-officedocument.presentationml.template,.ra,audio/x-pn-realaudio,.ram,.rm,application/vnd.rn-realmedia,.rtf,application/rtf,.sit,application/x-stuffit,.sitx,application/x-stuffitx,.tar,application/x-tar,.tgz,.tif,image/tiff,.tiff,.txt,.wav,audio/x-wav,.webm,video/webm,.wma,audio/x-ms-wma,.wmv,video/x-ms-wmv,.xls,application/vnd.ms-excel,.xlsx,application/vnd.openxml_formats-officedocument.spreadsheetml.sheet,.xltx,application/vnd.openxml_formats-officedocument.spreadsheetml.template,.zip,application/zip,.zipx,.graphql" type="file" name="Image1" class="file" id="userform__form_2584_Image1"/>
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| </div>
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| </div>
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| <div id="userform__form_2584_Image2_Holder" class="userdefinedthing field _input-wrap _input-wrap--file _form-group--no-_label file _form-group--no-_label">
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| <div class="file-drop-area">
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| <span class="fake-btn">Choose file</span>
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| <span class="file-msg js-set-number">or drag and drop a file here</span>
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| <_input type="hidden" name="MAX_FILE_SIZE" value="5242880000"/>
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| <_input class="file-_input" accept=".ace,application/x-ace-compressed,.arc,application/x-freearc,.arj,.asf,video/x-ms-asf,.au,audio/basic,.avi,video/x-msvideo,.bmp,image/bmp,.bz2,application/x-bzip2,.cab,application/vnd.ms-cab-compressed,.cda,.csv,text/plain,.dmg,application/x-apple-diskimage,.doc,application/msword,.docx,application/vnd.openxml_formats-officedocument.wordprocessingml.document,.dotx,application/vnd.openxml_formats-officedocument.wordprocessingml.template,.flv,video/x-flv,.gif,image/gif,.gpx,application/gpx+xml,.gz,application/gzip,.hqx,application/mac-binhex40,.ico,image/x-icon,.jpeg,image/jpeg,.jpg,.kml,application/vnd.google-earth.kml+xml,.m4a,.m4v,video/x-m4v,.mid,audio/midi,.midi,.mkv,video/x-matroska,.mov,video/quicktime,.mp3,audio/mpeg,.mp4,video/mp4,.mpa,.mpeg,video/mpeg,.mpg,.ogg,audio/ogg,.ogv,video/ogg,.pages,.pcx,image/x-pcx,.pdf,application/pdf,.png,image/png,.pps,application/vnd.ms-powerpoint,.ppt,.pptx,application/vnd.openxml_formats-officedocument.presentationml.presentation,.potx,application/vnd.openxml_formats-officedocument.presentationml.template,.ra,audio/x-pn-realaudio,.ram,.rm,application/vnd.rn-realmedia,.rtf,application/rtf,.sit,application/x-stuffit,.sitx,application/x-stuffitx,.tar,application/x-tar,.tgz,.tif,image/tiff,.tiff,.txt,.wav,audio/x-wav,.webm,video/webm,.wma,audio/x-ms-wma,.wmv,video/x-ms-wmv,.xls,application/vnd.ms-excel,.xlsx,application/vnd.openxml_formats-officedocument.spreadsheetml.sheet,.xltx,application/vnd.openxml_formats-officedocument.spreadsheetml.template,.zip,application/zip,.zipx,.graphql" type="file" name="Image2" class="file _form-group--no-_label" id="userform__form_2584_Image2"/>
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| </div>
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| </div>
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| <div id="userform__form_2584_Image3_Holder" class="userdefinedthing field _input-wrap _input-wrap--file _form-group--no-_label file _form-group--no-_label">
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| <div class="file-drop-area">
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| <span class="fake-btn">Choose file</span>
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| <span class="file-msg js-set-number">or drag and drop a file here</span>
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| <_input type="hidden" name="MAX_FILE_SIZE" value="5242880000"/>
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| <_input class="file-_input" accept=".ace,application/x-ace-compressed,.arc,application/x-freearc,.arj,.asf,video/x-ms-asf,.au,audio/basic,.avi,video/x-msvideo,.bmp,image/bmp,.bz2,application/x-bzip2,.cab,application/vnd.ms-cab-compressed,.cda,.csv,text/plain,.dmg,application/x-apple-diskimage,.doc,application/msword,.docx,application/vnd.openxml_formats-officedocument.wordprocessingml.document,.dotx,application/vnd.openxml_formats-officedocument.wordprocessingml.template,.flv,video/x-flv,.gif,image/gif,.gpx,application/gpx+xml,.gz,application/gzip,.hqx,application/mac-binhex40,.ico,image/x-icon,.jpeg,image/jpeg,.jpg,.kml,application/vnd.google-earth.kml+xml,.m4a,.m4v,video/x-m4v,.mid,audio/midi,.midi,.mkv,video/x-matroska,.mov,video/quicktime,.mp3,audio/mpeg,.mp4,video/mp4,.mpa,.mpeg,video/mpeg,.mpg,.ogg,audio/ogg,.ogv,video/ogg,.pages,.pcx,image/x-pcx,.pdf,application/pdf,.png,image/png,.pps,application/vnd.ms-powerpoint,.ppt,.pptx,application/vnd.openxml_formats-officedocument.presentationml.presentation,.potx,application/vnd.openxml_formats-officedocument.presentationml.template,.ra,audio/x-pn-realaudio,.ram,.rm,application/vnd.rn-realmedia,.rtf,application/rtf,.sit,application/x-stuffit,.sitx,application/x-stuffitx,.tar,application/x-tar,.tgz,.tif,image/tiff,.tiff,.txt,.wav,audio/x-wav,.webm,video/webm,.wma,audio/x-ms-wma,.wmv,video/x-ms-wmv,.xls,application/vnd.ms-excel,.xlsx,application/vnd.openxml_formats-officedocument.spreadsheetml.sheet,.xltx,application/vnd.openxml_formats-officedocument.spreadsheetml.template,.zip,application/zip,.zipx,.graphql" type="file" name="Image3" class="file _form-group--no-_label" id="userform__form_2584_Image3"/>
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| </div>
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| </div>
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| <div id="EditableTextField_5f85e" class="field field CompositeField composite _form-group--no-_label">
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| <div class="middleColumn">
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| <p>Before uploading your images, please read the <a href="image-use-policy/image-upload-terms/" target="_blank">Image Upload Terms</a>.</p>
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| </div>
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| </div>
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| <div id="EditableTextField_0ae6b"class="_input-wrap _input-wrap--checkbox field checkbox">
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| <div class="middleColumn">
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| <_input type="checkbox" name="EditableTextField_0ae6b" value="1" class="checkbox" id="userform__form_2584_EditableTextField_0ae6b"/>
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| <_label class="left" for="userform__form_2584_EditableTextField_0ae6b">Sign me up to get news and updates</_label>
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| </div>
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| </div>
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| <div id="userform__form_2584_EditableTextField_4eb70_Holder" class="field _input-wrap _input-wrap--nocaptcha _form-group--no-_label nocaptcha _form-group--no-_label"> | | <_label for="explanation">Image Explanation</_label> |
| <div class="g-recaptcha" id="Nocaptcha-userform__form_2584_EditableTextField_4eb70" data-sitekey="6LfgCEEUAAAAALS20SYaUYO2juKQ5jaimAQ3wHM6" data-theme="light" data-type="image" data-size="normal" data-_form="userform__form_2584" data-badge=""></div> | | <_input type="textarea" rows="4" id="explanation" name="explanation" required="required" placeholder="Image or file explanation.."/> |
| <noscript>
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| <p>You must enable JavaScript to submit this _form</p>
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| </noscript>
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| span class="bar"></span>
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| </div>
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| </div>
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| <_input type="hidden" name="SecurityID" value="5f0afdf273aad44869c942365cb994222718a60a" class="hidden" id="userform__form_2584_SecurityID" /> | | <_input type="file" id="file-upload" multiple="multiple" parsecontent target="pictures-[filename]-[mwrandom]" pagecontent="Information for this image: [description]" force="jpg" /> |
| <div class="clear"><!-- --></div>
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| </div>
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| <nav class="btn-toolbar Actions">
| | <_input type="submit" value="upload" /> |
| <_input type="submit" name="action_process" value="Submit photos and upload" class="action" id="userform__form_2584_action_process" /> | | </_form></div> |
| </nav> | | <templatestyles src="Contact/styles.css" /> |
| </_form> | |
