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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].

Which country do you reside in? Changing Faces cannot offer skin camouflage appointments to those based in Wales and Northern Ireland at this time, but can take expressions of interest from those based in Wales.

EnglandScotlandWales

Contact Information

First Name:

Last Name:

Pronouns

He/Him	She/Her
They/Them	He/They
She/They	Self-described
Prefer not to say

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 5-15 years old):

Mobile Number:

Enter home number here if no mobile

Home Phone Number:

Email Address:

Are you happy for us to leave a voice message?

NoYes

Street Address

Please start entering your address here

Town/City:

Post Code:

Nation/State

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Referral Details

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

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

Condition(s):

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

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

Site on Face/Body:

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

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:

If unsure, write 'unknown' or 'multiple'.

Your GP's practice/surgery name:

Your surgery/GP's street address:

Start typing the surgery/GP's address

Your surgery/GP's Town/City:

Your surgery/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

Any additional notes:

Demographic Information

Gender:

MaleFemalePrefer not to saySelf-described

Do you identify as the gender you were assigned at birth?

YesNoPrefer not to say

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

Contact preferences and submission

How did you find out about referring to the Skin Camouflage Service?

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
Work (colleague, employer, etc.)	Other (please specify)

Please provide detail

We'd love to stay in touch

Yes, you may use my email address to share the latest advice, services (including updates about skin camouflage), news, stories, and ways to get involved.

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.

Important Note - please check through each page of this form to ensure we have the correct contact details for you, otherwise we will be unable to process your referral.

Logged by Professional?

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