prestigeanklefoot.com - Photography Consent

Prestige Ankle & Foot Care, LLC is committed to providing high quality healthcare to its patients. As such, the use of clinical photography is limited to the purposes of diagnosis, treatment, and professional education. For the purpose of this consent, multimedia imaging includes photography, videotaping, and audiotaping

I, First Name Last Name Date of Birth consent to medical images and/or video being made of me or my child (or person for whom I am legal guardian). I understand that this will be made part of my legal medical record. The imaging may also be used for medical education and/or publication in medical journals. I understand that I will not be made payment from any party. I agree that duplicates may be made for the referring physician (if applicable). Refusal to consent to photographs, video, and/or audio recording will in no way affect the medical care I will receive. If I have any questions or wish to withdraw my consent in the future, I may contact the staff at Prestige Ankle & Foot Care, LLC.

By signing below, I confirm that I understand this consent form and have been given the opportunity to ask all questions. The responses to these questions have been satisfactory for me.

Please choose an option:

1. I consent for these photographs to be used in medical publications, including medical journals, textbooks, and electronic publications. I understand that the image may be seen by members of the general public, in addition to scientists and medical researchers that regularly use these publications in their professional education. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also agree for my image to be shown for teaching purposes at Prestige Ankle & Foot Care, LLC and to be used in my medical record.

Patient Signature

Date

2. I agree for my image to be shown for teaching purposes AND to be used for my medical record but NOT FOR medical publication.

Patient Signature

Date

3. I agree to the use of my image for medical records ONLY.

Patient Signature

Date

Medical Photography Consent