Complete Your Referral

First Name:

Last Name:

Date of birth:

Must be 5 years old or over

Age Group

5-1516+

If you are a parent or guardian filling in this form for your child, please fill in your name (must be completed if child 5-11 years old):

10-digit NHS number (England) - your GP surgery holds this information and an appointment cannot be offered without it:

If you don't have this, please enter 0000000000 and get in touch.

Mobile Number:

Enter home number here if no mobile

Home Number:

Are you happy for us to leave a voice message?

NoYes

Email Address:

1st Line Address

2nd Line Address

3rd Line Address

Town/City:

Post Code:

Your GP's name:

Your GP's practice name:

Your GP's address line 1:

Your GP's address line 2:

Your GP's address line 3:

Your GP's postcode:

Your GP's telephone number:

Your GP's email address (Leave blank if not known):

Have you discussed this referral with your GP?

NoYes

Self-describes as:

Ethnicity:

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Self-described (please specify):

Sexual orientation:

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Self-described (please specify):

Religion or belief:

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Self-described (please specify):

Do you consider yourself to have a disability?

NoYes

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.

Acne	Alopecia
Birthmark	Burns
Chloasma	Craniofacial/Maxillofacial
Dark pigmentation	Eczema
Granuloma	Hyperpigmentation
Hypopigmentation	Limb amputation/reconstruction
Melasma	Moles
Necrobiosis	Oncology/cancer
Plastics/prosthesis	Port wine stain
Psoriasis	Rosacea
Scarring	Severe blushing
Telangiectasia	Veins
Vitiligo	Xanthelasma
Other

Arm	Back
Buttocks	Chest
Face	Feet
Genitals	Hands
Lower Legs	Neck
Scalp	Shoulders
Stomach	Upper Legs

Changing Faces Website	Word of mouth
Health professional recommendation	Facebook
Twitter	Instagram
Google Search	Press (TV, newspaper)
Leaflet or poster	Other (please specify)

Complete your referral to our Skin Camouflage Service

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