Peds Photo Request
Please note this is the first step in the process of obtaining professional photos. An order form and signed permission slip will also be required. Once this form is received, we will contact you to follow up with the next steps in the process. Please contact us at
if you have any questions.
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Is this a Time Sensitive Request (ie the patient could pass in the very near future)
County Patient Resides in
Patient's Ethnicity (for grant purposes only)
Contact Number where YOU can be reached
Patient First & Last Name
Patient's Date of Birth
Parent/Adult Name (First and Last)
The Adult name listed above is the patient's:
Grandparent/Aunt/Uncle or other immediate relative
Legal Guardian (but not mother/father)
Foster Care Representative
Contact Number for Parent/Guardian
Please provide brief comment on overall condition of patient (ie feeding tube/oxygen/etc)
Please indicate where photos should be delivered
Please deliver to me
Please deliver to patient at their mailing address
Any other notes/comments/concerns that Photographer should be aware of
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Hospice and PalIative Care Foundation.