Consent to Photograph Form for SFHT

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CONSENT TO PHOTOGRAPHY AT KINGS MILL 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 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: ………………………………………………….
REQUESTERS SIGNATURE………………………….…...………………………………….………...........
Area to be photographed (please state):................………………………………………………………
Views required (to include measurements if necessary):……………………………………………...
NOTE FOR PATIENTS
We have arranged a “drop-in” session with the Clinical Illustration Department, on Level One, above
The Kings Mill Conference Centre, Mansfield Road, Sutton in Ashfield Nottingham NG17 4JL
On:
TUESDAY MORNING from
8:30am to 11:30am hours
If these times are really difficult for you please contact 01623 622515 extension 3649
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
Will view images electronically on the Orion
system
Please include a measure
in the close-up view
Date……………………….
Photographer…………….......
Location…………………..
Saved on the Orion Clinical System
Form updated September 2013
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