GP pro forma for photography at NCH

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CONSENT TO PHOTOGRAPHY AT NOTTINGHAM CITY HOSPITAL
Medical Photography
Patient Name:
I wish to refer you to Medical Photography for clinical photographs to be
taken. These images will be part of your medical records and will be used
to assess your eligibility for NHS funded treatment, in line with the
Commissioning Policy for Cosmetic Procedures (All Ages)
NHS No:
DOB:
Address:
Please Note: Clinical Photographs are NOT required for patients
requesting Breast Asymmetry or Breast Reduction Surgery
In view of the explanation given to me by:
I consent to photographs being taken to assess my eligibility for NHS funded treatment
Signature of patient /parent /guardian:…………………………………………….............................…….
Print Name:....................................................... Relationship if not patient: …………………………….
Date ……….............................……………….. Practice:
REQUSTERS SIGNATURE………………………….…...………………………………….………....................………
Area to be photographed (please state) :................…………
Views required (to include measurements if necessary):…………………………………
NOTE FOR PATIENTS
We have arranged two “drop-in” sessions per week with Medical photography at Nottingham City
Hospital, Hucknall Road, Nottingham, NG5 1PB. Please follow signs for North Corridor, Junction N6
These are:
TUESDAY AFTERNOON from 13:00 to 15:45 hours and FRIDAY MORNING from 08:30 to 12:15
If these times are really difficult for you please contact 0115 9691169 extension 56493
Please attend for clinical photographs as soon as possible; it is very important that you attend as we may
not be able to assess your G.P.’s referral and this may delay any treatment which you may require. Please
confirm with your GP when you have attended and had your photographs taken
NOTE FOR PHOTOGRAPHER
Please up load images to GP Referral
database (NUH Secure Clinical System).
Please include a measure
in the close-up view
Date……………………….
Location…………………..
Form updated September 2013
Photographer…………….......
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