Complete Your Referral

First Name:

Last Name:

Pronouns

Pronouns (Self-described)

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:

Mobile Number:

Enter home number here if no mobile

Home Phone Number:

Are you happy for us to leave a voice message?

NoYes

Email Address:

1st Line Address (Number and street)

2nd Line Address

3rd Line Address

Town/City:

Post Code:

Are you interested in:

A face-to-face appointmentOnline or phone sessionBoth

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

Which clinic would you like to attend?

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Referral Clinic

Please state your condition(s) if you selected ‘Other’:

Additional information about your condition(s) (if needed):

Do you have any known allergies to cosmetic products, e.g. lanolin, nickel, parabens etc?

NoYes

If so, please provide details of any allergies:

Do you have any infectious conditions present that would pose a risk to the Skin Camouflage Practitioner?

NoYes

Is your skin currently broken, inflamed or infected?

NoYes

Do you have any access needs eg: language, physical needs (such as difficulties with stairs), or preferences re practitioners? :

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

Your Doctor/GP's name:

Enter 'unknown' if not sure

Your GP's practice/surgery 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

Demographic Information

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):

Have you previously served in the armed force?

YesNoPrefer not to say

Do you consider yourself to have a disability?

YesNoPrefer not to say

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 Appeal/Campaign	Education Professional (e.g. teacher, youth worker, lecturer)
Event (online or face to face)	Family/Friend
Health or Social Care Professional	Leaflet or poster
Media (Newspaper, Radio, TV, etc.)	Other Changing Faces service
Other visible difference organisation	Other website or organisation
Search Engine	Social Media
Word of mouth	Work (colleague, employer, etc.)
Other (please specify)

Complete your referral to our Skin Camouflage Service

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