Colorectal Surgery Photography and Video Recording Consent Form

Patient Information

Name: _________________________
Date of Birth: __________________
Medical Record #: _______________

Authorization

I, _________________________________, hereby authorize Dr. _________________________ and [Practice Name] to take and/or record:

• Photographs
• Video recordings
• Digital images

of my colorectal condition, surgical procedure(s), and/or treatment outcomes.

Permitted Uses

I understand these images/recordings may be used for:

1. Medical documentation and treatment planning
2. Educational purposes for medical professionals
3. Quality assurance and surgical technique evaluation
4. Medical research and publication in scientific journals
5. Patient education materials

Privacy and Confidentiality

• All images/recordings will be stored securely in accordance with HIPAA regulations
• My identity will be protected in any public use of these materials
• Facial features will not be included unless specifically authorized
• I may revoke this authorization in writing at any time

Duration

This authorization remains valid for:

• This episode of care only
• Indefinitely
• Other: _______________

Signatures

Patient Signature: _________________________
Date: _______________

Witness Signature: _________________________
Date: _______________

Physician Signature: _______________________
Date: _______________

Revocation

To revoke this authorization, contact our office in writing at [Practice Address].