Peds Photo Request
Email address *
Is this a Time Sensitive Request (ie the patient could pass in the very near future) *
County Patient Resides in *
Your answer
Patient's Ethnicity (for grant purposes only) *
Required
Contact Number where YOU can be reached *
Your answer
Patient First & Last Name *
Your answer
Patient Age *
Your answer
Patient's Date of Birth *
MM
/
DD
/
YYYY
Parent/Adult Name (First and Last) *
Your answer
The Adult name listed above is the patient's: *
Contact Number for Parent/Guardian *
Your answer
Texting ok? *
Address where photo session will take place (please make sure to include city, state, and zip *
Your answer
Mailing Address (if different from above)
Your answer
Please provide brief comment on overall condition of patient (ie feeding tube/oxygen/etc) *
Your answer
Please provide a brief description of the setting that the photo shoot will be held (ie dwelling/mobile home/apartment/ foster care facility etc) *
Your answer
How many family members do you anticipate participating in the shoot? (please keep in mind this is for immediate family members only) *
Your answer
Ages of any siblings/additional children you anticipate participating in the photo session (if more than one sibling please format like example: sarah 6, jason 8, peter 12) if none please type n/a *
Your answer
Do you plan on being present at the shoot? *
For the remainder of 2017- Choice of Prints or Digital copy (via jump drive) Any sessions completed after Jan 1st 2018 will automatically receive Digital copies- NO PRINTS *
Are you requesting a video (delivered via jump drive) for this patient? *
Contact Email for Parent/Guardian
Only include email address if you are requesting a Video and the parent has an email address they check regularly.
Your answer
Please indicate where photos should be delivered *
Any other notes/comments/concerns that Photographer should be aware of
Your answer
A copy of your responses will be emailed to the address you provided.
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