Cardiac Surgery Photography and Video Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: _____________________

Authorization

I, ______________________, hereby authorize [Hospital/Practice Name] and its cardiac surgery team to:

• Take photographs, video recordings, and/or digital images
• Store these images in my medical record
• Use these images for the following purposes (check all that apply):

□ Medical documentation and treatment planning □ Educational purposes within the medical community □ Quality assurance and peer review □ Research purposes (requires additional research consent) □ Medical publications or presentations

Understanding and Agreement

1. I understand that these images will become part of my medical record.
2. I understand that these images may include identifying features.
3. I understand that if used for educational or research purposes:
   • My identity will be protected unless specifically authorized
   • No commercial use will be permitted without separate consent
   • Images will be handled according to HIPAA regulations

Specific Restrictions (if any)

Signatures

Patient/Legal Guardian: _________________ Date: __________ Witness: _____________________________ Date: __________ Physician: ___________________________ Date: __________

Revocation

This authorization can be revoked at any time by written notice to [Hospital/Practice Name], except for actions already taken in reliance on this authorization.

Form ID: CARD-PHOTO-001 Version: 2.0 Last Updated: [Date]