Gastroenterology Procedure Photo/Video Consent Form

Patient Information

Name: ________________________________ Date of Birth: _________________________ Medical Record Number: _________________

Authorization

I, _________________________, hereby authorize [Practice Name] and its affiliated healthcare providers to:

• Take photographs, video recordings, and/or digital images
• Store these media files in my medical record
• Use these images for medical documentation, education, and quality improvement

Permitted Uses

I understand these images may be used for:

1. Medical documentation and procedure recording
2. Educational purposes (including medical training and education)
3. Quality assurance and improvement initiatives
4. Scientific publications and medical presentations
5. Patient education materials

Understanding and Agreement

I understand that:

• These images will become part of my confidential medical record
• My identity will be protected in any public use of these images
• I can revoke this authorization in writing at any time
• Refusing to sign will not affect my medical care

Signature Section

Patient Signature: _____________________ Date: ________________________________

Witness Name: ________________________ Witness Signature: ____________________ Date: ________________________________

Practice Authorization

Physician Name: _______________________ Signature: ____________________________ Date: ________________________________

[Practice Name and Contact Information]

Form Version: [Date]