Pre Consultation Photo Consent

Pre Consultation Photograph Consent

Patient First Name *

Patient Surname *

Procedure

I give permission for photographs I have provided prior to my consultation:

To be sent to my referring Surgeon for triage To be sent to another Surgeon in our practice for triage (in case your referring surgeon is not available) As part of my consultation

At your request, we can also remove any identifying marks ie: tattoos or birthmarks. Please write your request:

Please note that all photographs will be de-indentified where possible and therefore will not have any names or faces attached.

Signature *

Draw signature|Type signatureClear

Date *