Send a photo | Murieston Medical Practice

Who should use this form?

You should only use this form if you have been asked by your doctor, or a Practice nurse, to send a photo.

If you have not been asked to send a photo, do not use this form.

Your details

First name

Last name

Phone number

Door number / property name

Post code

Choose clinician

Please tell us who requested the photo so we can ensure it gets to them.

Clinician who requested the photo

Important reminder
Do not send photos unless they have been been requested by the clinician you have specified. Unrequested photos will not be processed.

Choose photos

You can choose up to three photos to send to us.

Helpful information

Files types you can upload: .jpg, .jpeg, and .png
Maximum file size: 3 MB
You can choose up to three photos to send

How to take an optimal photo for your clinician

Before taking your photo, we recommend reading the following tips.

If it is not immediately obvious where the issue is, indicate its location with your finger or other pointer, digital annotation, etc.
Where appropriate, include a cleaned ruler or coin next to anything that may need a scale reference.
Make sure there is plenty of light (natural daylight is best), and try to avoid using the flash function where possible.
Make sure the photo is clear, in focus, and not blurred.
If you are using a smartphone, don't use the digital zoom function. Instead, move your phone closer.
Try not to cast shadows over the area you are photographing.
Where possible, avoid including your face (or any other identifying marks) in the photo.

Photo

Choose a photo

If you want to send more photos, you can supply up to another two below.

Additional photo one

Choose a photo Optional

Additional photo two Optional

Choose a photo

Additional information

If you want to supply any additional details or information, please use this box.

Your email address

This form requires your email address so we can send you a confirmation receipt. Please supply one below.

Email address

Any photos you send us will not be included in the email receipt. This is to protect you in the case your email address is entered incorrectly.

Confirmations

We need you to read and confirm the following information in order to process this submission. Without these confirmations, we cannot continue.

I consent to forwarding the attached photograph(s) / image(s) to Murieston Medical Practice for the purposes of progressing the investigation and / or treatment of my injury / ailment.

I understand that I am doing so entirely at my own risk and that Murieston Medical Practice will not be held responsible in any way should the photograph(s) or email be misdirected to a third party during transit.

I expect Murieston Medical Practice to ensure that the photograph(s) and information contained in the email are used, stored and deleted in accordance with national guidelines and not transmitted to another party without my consent other than to secondary or tertiary care departments involved / potentially involved in the progression of my treatment to which the photograph(s) / image(s) refers.

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We use this technology to minimise automated message sending.

Security check

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The information you supply will be sent over a secure connection.