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 info@hpcfoundation.org if you have any questions.
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Email *
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) *
Required
Contact Number where YOU can be reached *
Patient First & Last Name *
Patient Age *
Patient's Date of Birth *
MM
/
DD
/
YYYY
Parent/Adult Name (First and Last) *
The Adult name listed above is the patient's: *
Contact Number for Parent/Guardian *
Texting ok? *
Mailing Address
Please provide brief comment on overall condition of patient (ie feeding tube/oxygen/etc) *
Please indicate where photos should be delivered *
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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