Template:Donate file

<_form id="userform__form_2584" action="/contact-us/submit-a-photo/_form" method="post" enctype="multipart/_form-data" class="userform" data-toperrors="data-toperrors">

<_label class="left" for="userform__form_2584_EditableTextField_6debd">Your name (full legal/company)</_label> <_input type="text" name="EditableTextField_6debd" class="text" id="userform__form_2584_EditableTextField_6debd"/>

<_label class="left" for="userform__form_2584_EditableTextField_f6b88">Email</_label> <_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"/>

<_label class="left" for="userform__form_2584_EditableTextField_da2bf">Address (include country) </_label> <_input type="text" name="EditableTextField_da2bf" class="text" id="userform__form_2584_EditableTextField_da2bf"/>

<_label class="left" for="userform__form_2584_EditableTextField_47c87">Tell us your profession or specialty</_label> <_select name="EditableTextField_47c87" class="dropdown" id="userform__form_2584_EditableTextField_47c87" > <_input type="option" value="Please _select">Please _select</_input> <_input type="option" value="Dermatology" _selected="_selected">Dermatology</_input> <_input type="option" value="Primary Care Physician">Primary Care Physician</_input> <_input type="option" value="Marketing/media">Marketing/media</_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="Medical student or physician in training">Medical student or physician in training</_input> <_input type="option" value="Patient or caregiver">Patient or caregiver</_input>

</_select>

<_label class="left" for="userform__form_2584_EditableTextField_f7377">Image diagnosis/caption</_label> <textarea name="EditableTextField_f7377" class="textarea" id="userform__form_2584_EditableTextField_f7377" rows="5" cols="20"></textarea>

<_label class="left" for="userform__form_2584_Image1">Upload photo(s)</_label>

Choose file or drag and drop a file here <_input type="hidden" name="MAX_FILE_SIZE" value="5242880000"/> <_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"/>

Choose file or drag and drop a file here <_input type="hidden" name="MAX_FILE_SIZE" value="5242880000"/> <_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"/>

Choose file or drag and drop a file here <_input type="hidden" name="MAX_FILE_SIZE" value="5242880000"/> <_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"/>

Before uploading your images, please read the <a href="image-use-policy/image-upload-terms/" target="_blank">Image Upload Terms</a>.

<_input type="checkbox" name="EditableTextField_0ae6b" value="1" class="checkbox" id="userform__form_2584_EditableTextField_0ae6b"/> <_label class="left" for="userform__form_2584_EditableTextField_0ae6b">Sign me up to get news and updates</_label>

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You must enable JavaScript to submit this _form

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<_input type="hidden" name="SecurityID" value="5f0afdf273aad44869c942365cb994222718a60a" class="hidden" id="userform__form_2584_SecurityID" />

<nav class="btn-toolbar Actions"> <_input type="submit" name="action_process" value="Submit photos and upload" class="action" id="userform__form_2584_action_process" /> </nav> </_form>