Requesting Practitioner

Dr:

Telephone:

Patient Details (Please Print Clearly)

Surname:

First Name:

Title: Miss / Mr / Ms / Mrs / Dr / Other

Gender: Male / Female Date of Birth:

Postal Address:

Postcode:

Mobile Telephone:

Imaging sessions are held at the following locations:Central Brisbane Dermatology Level 9, 101 Wickham Terrace, Spring Hill, Brisbane - Telephone 07 3831 4382

F45 Photography Studio (Adjacent to Oxley Railway Station) - Telephone 0455 345 345

Appointment Date: Time: Please bring this request form to your appointment

Note: The imaging session will take approximately 20 minutes. For best results, please wear brief undergarments and do not apply make-up, suncream or moisturiser or wear jewellery. Long hair should be tied back so that it does not mask large areas of skin.Your set of reference images will record the face, shoulders, chest, back, waist, arms, legs and feet. Images will be presented via return mail as a folio of A4 photographic prints. You should receive your image folio within two weeks of your imaging session.

The following payment methods are accepted

Skin Photography Request