Providing support and promoting respect for everyone with a visible difference

Support line: 0300 012 0275Donate

Complete your referral to our Skin Camouflage Service

Please fill in this form to complete your referral for a Skin Camouflage Service appointment.

A health professional acting on your behalf has recently requested a Skin Camouflage Service appointment for you. We’re nearly ready to book your appointment but need a bit more information about you before we can do that.

Please complete the secure and confidential form below. Please note that we cannot book your appointment until you have filled in this form.

If you are in England, you will need your NHS number to hand when completing the form. You can find this on any written correspondence from your GP surgery or can get it by contacting them directly. If you live in Scotland, you will not be asked for this on the form.

What happens next? Once complete, a member of the skin camouflage team will assess your needs and will contact you by phone or email when an appointment becomes available at our closest clinic to you.

Complete Your Referral

If you have any difficulties completing this form or have any other questions, please contact the Skin Camouflage Service on 0300 012 0276, or email [email protected].

If you have any difficulties completing this form, or have any other questions, please contact the Skin Camouflage Service on 0300 012 0276, or email [email protected]

Must be 5 years old or over

Enter home number here if no mobile

Please note, we are unable to provide a colour match at online or phone sessions – see here for more information

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Please note that Skin Camouflage Practitioners speak English, work alone and can be of any gender

Enter 'unknown' if not sure

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You can change what you receive at any time and we will never sell your details to third parties.

Our privacy policy is below. We take the protection of your personal data very seriously. We will treat your personal data confidentially and in accordance with the statutory data protection regulations. By providing us with your data, you give us permission to record your details on our secure database. We will use your details to correspond with you and to enable us to provide you with our service. We will ask the CCG where your GP is registered to contribute to the cost of your treatment and in some cases this may mean that we share some of your data securely with NHS bodies. After your treatment is complete, your data will be used anonymously for statistical purposes only. We will never use your data for any other purpose or share your data without your permission. 

Please ensure you've read our privacy statement before submitting your referral.