Providing support and promoting respect for everyone with a visible difference

Support line: 0300 012 0275Donate

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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]

Contact Information

Must be 5 years old or over

Enter home number here if no mobile

Please start entering your address here

Referral Details

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

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

Start typing the surgery/GP's address

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Contact preferences and submission

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.