Clinical Photo Capture Form
Clinical Photo Capture Form
Session Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient or Client Full Name
*
First Name
Last Name
Session Location
*
Referring Clinician
Photo Type / Area
*
Please Select
Face
Torso
Limbs
Other
Purpose of Photos
*
Please Select
Documentation
Treatment Planning
Progress Tracking
Other
Consent Obtained
*
Yes
No
Upload Clinical Photos
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Staff Member Capturing Photos
*
Additional Notes
Submit
Should be Empty: