Neurosurgical Procedure Photo/Video Documentation Consent Form

I, _________________________________ (print patient name), hereby authorize Dr. _________________________ and [Hospital/Practice Name] to take, produce, and use clinical photographs, video recordings, and/or digital images of my neurosurgical procedure(s), associated conditions, and treatment outcomes.

Purpose and Usage

• Medical documentation and clinical records
• Educational purposes for medical professionals
• Scientific publication and research
• Quality assurance and surgical planning

Terms and Conditions

1. Identity Protection

   • Reasonable efforts will be made to protect my identity
   • My name will not be used in connection with the images
   • Identifying features may be obscured when possible

2. Permitted Uses

   • Medical conferences and presentations
   • Professional medical journals
   • Teaching materials for medical education
   • Internal hospital/practice documentation

3. Ownership and Rights

   • All images/recordings remain property of [Hospital/Practice Name]
   • No commercial use without additional written consent
   • No compensation will be provided for use of images

Authorization

I understand that:

• This authorization is voluntary
• I may revoke this authorization in writing at any time
• Revocation will not affect any prior use of images/recordings
• This authorization has no expiration date unless specified

Patient Signature

Date

Witness Signature

Date