Patient Photo and Video Release Authorization Form

I, ______________________ (print name), hereby authorize [PRACTICE NAME] and its staff to take and use photographs, video recordings, digital images, and/or audio recordings of me (or my dependent) for the following purposes:

Authorized Uses

• Medical documentation and electronic health record maintenance
• Medical education and training
• Academic medical publications
• Quality improvement initiatives
• Marketing materials (if specifically initialed below)

Understanding and Agreement

I understand that:

1. These images/recordings may reveal identifying features and medical conditions.
2. All efforts will be made to protect my privacy and confidentiality.
3. I will not receive compensation for any use of these materials.
4. I may revoke this authorization in writing at any time, but this will not affect materials already used.

Specific Authorizations

Please initial next to approved uses:

___ Medical documentation and treatment planning
___ Teaching and training of medical professionals
___ Medical publication and research
___ Practice marketing materials and website
___ Social media content

Duration

This authorization remains valid for:

• One-time use only
• Duration of treatment
• Indefinitely
• Other: ________________

Signatures

Patient/Guardian Signature: ___________________ Date: ___________

Witness Signature: __________________________ Date: ___________

Practice Representative: _____________________ Date: ___________

This authorization is governed by HIPAA regulations and state privacy laws.