Molluscum Parent Form

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Please do not use a private browser or incognito mode as they disable functions that our medical form and checkout page require.
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Terms and Notices* This field is required.
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Parent/Guardian's Name* This field is required.Please enter your legal name as shown on your driver license.
First Name
Last Name
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Child's Name (Minor)* This field is required.Please enter their full legal name.
First Name
Last Name
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Parent/Guardian's Email Address* This field is required.
example@example.com
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What is your child's (minor's) birthdate?* This field is required.To change the year on a mobile device, click on the year in the calendar.
Date
Month
Day
Year
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Which state do you live in?* This field is required.Please select your state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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What is your child's (minor's) biological sex?
Male
Female
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State Calculator
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In the next section you will be asked to upload a clear picture of your (PARENT/GUARDIAN's) face, and a photo of your government-issued ID to comply with telehealth laws.

Your assigned provider is based on your state of residence. To see our list of providers visit EasyDerm.com/providers.
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How would you like to upload your photos?
Use CameraUpload
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Provide a picture of your (PARENT/GUARDIAN'S) face. Ensure that:

1. Your entire face is well lit, clear, and visible

2. You're the only person in the photo

3. Nothing is covering your face
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Upload photo of guardian's face
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Photo of guardian's face
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Please provide the PARENT/GUARDIAN's identification to comply with telehealth laws.

1. ID card is a valid driver license or passport

2. Photo is clear, and all edges are showing

3. Full name and DOB are visible
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Upload guardian's driver license or passportIf you wish to provide your ID at a later time, click "Next" and skip this step.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Guardian's Driver License or Passport
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Attestation
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Based on the answers you provided we cannot prescribe you acne treatment through our online platform.

It is recommended that you follow-up with your primary care physician, or a dermatologist.
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Currently our telemedicine platform not operating in your state. However, we are planning to launch to your state by the end of the year!

We will send you a notification as soon as we're in your area!
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You will now be routed to the medical visit! Some questions will be repeated to ensure guardian-child identification.
Should be Empty: