• Wound Photography Consent Form

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  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Photographs for my care

    I agree that PNW Wound Specialist LLC may photograph my wounds to document their condition and healing in my medical record and support medically necessary care and insurance billing. The clinician will protect my privacy and discuss any concerns before taking a photograph.

    Clinical photographs are protected health information. They may be used or disclosed for permitted treatment, payment, health care operations, or other purposes allowed by law, as described in our Notice of Privacy Practices.

    Optional education choice

    The choice below is optional and does not affect my treatment or benefits. If I agree, only photographs properly de-identified under HIPAA may be used for professional education or training. Staff must remove identifying features and assess the possibility of identification before use. This form does not authorize identifiable photographs, advertising, social media, or marketing.

  • Optional use of de-identified wound photographs for education or training (choose one)*

  • I may ask questions, decline optional education use, or change my permission for future photographs or education use by contacting PNW Wound Specialist LLC at 509-209-9033. A change does not undo a use already made in reliance on my permission. Photographs already part of my medical record remain subject to record retention requirements.

    My signature confirms my clinical photograph consent and the optional choice I selected. A legally authorized representative may sign when permitted; staff must verify their authority.

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: