Patient Photography and Video Release Authorization Form

I, _________________________________ (print name), hereby authorize Dr. _________________ and [Practice Name] to take, produce, and use clinical photographs, videos, digital images, and/or other visual recordings of me (or my dependent) for the following purposes:

Authorized Uses

• Medical documentation and treatment planning
• Educational purposes for medical professionals
• Scientific publication in medical journals
• Professional presentations at medical conferences
• Patient education materials

Understanding and Agreement

I understand that:

1. These images may include recognizable features of my (or my dependent's) body, including surgical sites, range of motion demonstrations, and physical examination findings.

2. All images will be stored securely and handled in compliance with HIPAA regulations.

3. My name and identifying information will not be published or disclosed without additional specific consent.

4. I may revoke this authorization at any time by written notice, but such revocation will not affect any images already used.

Consent

• I consent to all uses listed above
• I consent only to medical documentation purposes
• I decline all photography/videography

Patient/Guardian Signature: _______________________ Date: _______________

Witness Signature: _______________________ Date: _______________

Practice Use Only

Image Reference Numbers: _______________________ Date Recorded: _______________________ Staff Member: _______________________