Dermatology Photo and Video Consent Release Form

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: __________________ Date: _____________________

Authorization

I, ______________________, hereby authorize Dr. ______________________ and [Practice Name] to take, produce, reproduce, and use photographs, digital images, and/or video footage of my skin condition(s), treatment(s), and procedure(s) for the following purposes:

• Medical documentation and electronic health records
• Educational purposes, including medical teaching
• Scientific publications and presentations
• Marketing materials and patient education
• Before and after treatment comparisons

Understanding and Consent

I understand that:

1. These images may include identifying features
2. All efforts will be made to protect my privacy and confidentiality
3. I may request to view the images taken
4. I may withdraw this consent at any time in writing
5. Withdrawal of consent will not affect images already in use

Usage Rights

• The images remain the property of the practice
• No compensation will be provided for their use
• Images may be stored indefinitely in secure medical records

Specific Restrictions (if any)

Signatures

Patient Signature: _________________ Date: __________

Witness Signature: _________________ Date: __________

Physician Signature: _______________ Date: __________

This consent form is valid for 10 years from the date of signing unless revoked in writing.