form-image

Image upload form

Participant Information

First name

Last name

Phone

Address information

Company

Address

Postal Code

City

Country

Message

Labeling: The images must be labelled in the file name with contestant’s last name and name followed by submission number of the image, example: DoeJohn1

Image 1

First name/last name

Disease/Diagnosis

Device used

Image 1

Add additional image?
All fields are mandatory. Please complete all fields otherwise your entry will not be considered.

Image 2

First name/last name

Disease/Diagnosis

Device used

Image 2

Add additional image?
All fields are mandatory. Please complete all fields otherwise your entry will not be considered.

Image 3

First name/last name

Disease/Diagnosis

Device Used

Image 3

Add additional image?
All fields are mandatory. Please complete all fields otherwise your entry will not be considered.

Image 4

First name/last name

Disease/Diagnosis

Device used

Image 4

Accept Participation terms

Accept Privacy Policy

Please confirm that you have read & understood the Participation terms & Privacy Policy by checking the boxes above. Both boxes must be checked to submit your entry.

Image upload form

Haag-Streit Group

Contact

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Image upload form