Patient Photography and Video Recording Authorization Form

I, _________________________________ (print patient name), hereby authorize [PRACTICE NAME] and its affiliated healthcare providers to photograph, video record, and/or audio record me or my dependent during neurological examinations, procedures, or treatments for the following purposes (check all that apply):

Authorized Uses

• Medical documentation and treatment planning
• Educational purposes (teaching medical students, residents, or other healthcare providers)
• Research purposes
• Publication in medical journals or textbooks
• Marketing or promotional materials

Terms and Conditions

1. I understand that these images/recordings may include documentation of:

   • Neurological examinations
   • Movement disorders
   • Seizure activity
   • Diagnostic procedures
   • Treatment procedures

2. I understand that:

   • My identity may be recognizable in these materials
   • I have the right to revoke this authorization at any time
   • Refusing to sign will not affect my medical care
   • Materials already in use cannot be recalled

Duration

This authorization is valid for:

• This visit only
• One year from the date of signature
• Indefinitely

Signatures

Patient/Guardian Signature: ___________________ Date: ___________

Witness Signature: __________________________ Date: ___________

Provider Signature: _________________________ Date: ___________

A copy of this authorization will be provided upon request.