Skin Problem

Dermatology Form

If you are able to upload a photo of your condition please complete this form. Once we have reviewed your images we will organise a prescription or a telephone consultation or video call with one of our clinicians.

Please use this link to help when sending in your photographs.

If you are unable to upload a photograph please call for a telephone or video appointment.

We will get back to you within 2 working days either by text or by call.

This form is not suitable for patients under 5 years.

Please don’t send photos of intimate body parts. This would need to be a face to face appointment.

First Name *

Last Name *

Date of Birth

Email *

Enter Email

Phone Number *

Please upload a photograph of the condition.

Maximum file size: 10MB

Can you describe your skin problem (eg how long have you had it, what symptoms does it cause, any triggers ? anything make better or worse)

What are your concerns or what are you worried about?

What have you tried already?

What were you hoping outcome would be eg referral/medication/advice.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I understand this can take up to 2 working days to receive a reply either by call or text.

I consent to the practice collecting and storing my data from this form.

If you are human, leave this field blank.