Photo and Video Consent Form

Photo and Video Consent Form

For educational, research and/or promotional use
This authorization grants permission to use your image (still or moving) and/or your spoken words in perpetuity for educational, research and/or promotional purposes. You are not obligated to give consent, and your decision will not affect your treatment, except where a treatment cannot be offered due to lack of photographic documentation.

Generally, photos and/or videos will be taken when necessary to document your progress and response to treatment will form a part of your confidential medical record. Unless you grant permission for promotional use, they will only be used for educational or research purposes as outlined below.
Please indicate the type of use you agree to (select all that apply):

Educational and research use only (identity protection if possible)Promotional, educational and research use where identity may be shown.Promotional use with identity protection (i.e. no identifying features shown)Other
By signing this document, you agree:
1. To allow the recording of your image and voice (e.g., photographs, audio, or video).
2. To distribute your image or recording in any medium, be it print or electronic form, which may include the Internet.
3. To grant permission to other entities to reproduce the images or recording for the purposes below (educational and/or promotional)
4. That there is no reimbursement for the right to take, or to use your photograph or video or recording.
5. Your consent or refusal will not affect the type or quality of treatment which would be recommended.
Restrictions and Limitations:

NoneOther
I have read and fully understand the intent and purpose of this document and am signing it without reservation.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: