Consent to Photograph Form for NUH

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Appendices 2B
Consent to Photography at Nottingham University Hospitals NHS Trust
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 by The Plastic
Surgery Working Group Panel to assess your referral.
NHS No:
DOB:
Address:
In view of the explanation given to me by:
I consent to photographs being taken for my hospital notes & Plastic Surgery Working Group Panel
Signature of patient /parent /guardian:…………………………………………….............................…….
Print Name:....................................................... Relationship if not patient: …………………………….
Date ……….............................………………..
Signature of Healthcare professional ………………..................... Practice ………………………….
Area to be photographed:................…………
Views
required:…………………………………
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
N13. These times are:
TUESDAY AFTERNOON from 13:00 to 15:45 and FRIDAY MORNING from 08:30 to 12:15
If these times are difficult or if you’d prefer to come to the QMC campus, please contact the
Medical Photography department on 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 include a measure
in the close-up view
NOTE FOR PHOTOGRAPHER
Please upload images to GP Referral
database.
Jane Urquhart
IFR Manager
Photographer………..
Date....................
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