Informed Consent and Release for Medical Photography and Media
Informed Consent and Release for Medical Photography and Media
Patient and Practice Information
1. Purpose and Capture of Medical Media
Medical photography and video recording are used in healthcare to document clinical findings, monitor treatment progress, assist in surgical planning, and support patient education. The media is captured during your visits by clinical staff using secure devices. Under privacy laws, you must authorize the capture of these images and specify how they may be stored, used, or shared. Images of sensitive body areas receive additional privacy protections. This form lets you choose which uses of your images you authorize.
2. Authorized Uses of Your Images (Select All That Apply)
3. De-identification and Face Masking Guidelines
The clinic will take all reasonable steps to protect your identity. For education and marketing uses, the clinic will crop or mask the images to cover your eyes or other identifying features where possible, unless the treatment area involves your face. Your name, date of birth, and medical record number will never be published alongside any images. However, you understand that unique tattoos, scars, or facial features might still allow someone to recognize you.
4. Media Ownership and Copyright Release
I understand that the photographs, videos, or recordings taken during my treatment are the legal property of this clinic. I do not own the copyright to these files. I waive any right to inspect or approve the finished media before publication. I understand that I am not entitled to any financial payment, royalties, or compensation for the use of these images in any format.
5. Risks of Public Media Sharing
6. Right to Revoke Consent
You have the right to revoke this consent at any time. Your revocation must be submitted in writing. Once received, the clinic will stop using your images in any new publications. However, you understand that images already published in print or shared on social media cannot always be recalled or deleted, and the clinic is not responsible for files already downloaded by the public.
7. Non-Conditioning of Treatment
Your medical treatment, surgery, or enrollment in clinical programs is not conditioned on signing this photography consent. You have the right to refuse to sign this form. Refusing will not affect your care, but will mean the clinic cannot take or use photos for anything other than your personal medical record (if clinical photos are required for treatment monitoring).
8. Alternatives to Photography
9. Expiration of Consent
This consent will remain active indefinitely unless you submit a written revocation. The clinic will store your medical media files in accordance with state records retention laws (typically 7 to 10 years after your last visit).
10. Patient Understanding and Questions
I confirm that I have read this document and understand the medical photography program, my options for image use, the de-identification steps, the waiver of copyright, and my revocation rights. All my questions have been answered.
11. Language Access Services
If English is not your primary language, a qualified interpreter is available at no cost. Please inform staff before signing.
12. Copy of Consent Acknowledgment
I acknowledge that I have been offered a copy of this signed consent form.
13. Patient Authorization
I voluntarily consent to the capture of clinical photographs, videos, or recordings of my treatment areas. I authorize the uses selected in the options section above and release the clinic from any claims regarding copyright or royalties.