FYPC patient photo and video submission

Please only use this form if you have been asked to send us a photo or recording.

Please select the service you are wanting to send the photo\recording to:
Service Name*
Which clinician has asked you to send the recording in?
Please record your\your child's details:
What is your Child's Name?*
What is your Child's Date of Birth?*
What's your home post code?*
What is your Child's NHS Number?
Leave blank if not known
Is there any information you want to share with the clinician?
Information to be shared:
Please attach your file below
If sending multiple files please submit one at a time.
File*
Max. file size: 25 MB.

PLEASE NOTE: The maximum file size is 25MB, if your file is larger than this you will need to split it and send it as separate files.
Please ensure your submission meets the below criteria
Please tick below to confirm that*
you agree that the photo\video adheres to the below criteria:
- You have been asked by a clinician to submit a photo or recording.
- Media must not be submitted without the consent (when age appropriate) of the child\young person.
- Please aim to prevent including any other persons in the photo\recording (we recognise this may not always be possible).
- If you are another professional, please ensure the photo\recording is taken in line with your local policy\guidelines.

Please select the service you are wanting to send the photo\recording to: