Patient Photograph(s) Request (Requested by a Clinician Only)

If you have been asked by a clinician to upload/attach a photograph(s) of your condition, please use this form.

Please note, if we do not have a record of a clinician requesting you to send in a photograph(s), the photograph(s) will be discarded.

If a clinician has not requested for you to send a photograph(s) but you have concerns over a mole/rash/lump/lesion etc, please contact the practice directly.

Patient Photograph(s) Request
Have you been requested to send in a photograph(s) by a clinician? *

Please note, if we do not have a record of a clinician requesting you to send in a photograph(s), the photograph(s) will be discarded.

We are sorry, this form is only to be used if a clinician has requested you to send in a photograph(s). If you continue to complete this form it will not be processed. Please contact the practice if you have a concern of a mole/rash/lump/lesion etc.

Section

Please attach your photograph(s) here as requested by the clinician:
Drop a file here or click to upload Choose File
Maximum upload size: 67.11MB

This photograph(s) is classed as sensitive and will be stored appropriately on your clinical record if it will assist the clinician with an ongoing or future diagnosis, if this is not the case it will be destroyed within 30 days if no longer required. By sending us the photograph(s) you agree to these conditions.

Please view our Privacy Notice for more information

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