Photography Request Form

Photography request form

Please complete the form below, required fields = *
  • :
  • :
  • MM slash DD slash YYYY
  • Please provide address and directions to location
  • Format (###)###-###
  • Name (please note, if more than one subject, please name them in the description filed):
  • Title:
  • College and department:
  • Contact number:
  • One to two words
  • Description of your photography project including intended audiences and types of medium images will be reproduced in. If you have a desired “look” or an idea for your photography project please include links to sample images with photo request.
  • Please enter relevant keywords separated by commas.
  • Enter PHI consent information: Treating physician, service line/campaign name/news story, staff member obtaining consent, etc...
  • Check all boxes for the appropriate uses of these photos, and then remember to check off all boxes when having the PHI form signed by the patient. (As many as possible so that photos can be used for multiple purposes.)
  • Please list the publication(s) this photo is intended for
  • Please indicated designer working on this project.
  • MM slash DD slash YYYY