Pediatric Practice Photography and Video Release Authorization

Patient Information

Patient Name: ___________________________ Date of Birth: //___ Parent/Legal Guardian: _____________________

Authorization

I hereby authorize [Practice Name] ("the Practice") to capture and use photographs, digital images, videos, and/or audio recordings of my child for the following purposes:

Approved Uses (check all that apply):

• Medical documentation and electronic health records
• Patient care and treatment planning
• Educational purposes within the medical community
• Marketing materials (print and digital)
• Practice website and social media
• Scientific publications

Terms and Conditions

1. Duration: This authorization is valid until revoked in writing.
2. Ownership: All media remains the property of the Practice.
3. Privacy: No identifying information will be shared without additional consent.
4. Revocation: I may revoke this authorization at any time in writing.
5. No Compensation: I understand I will receive no financial compensation.

Limitations

This authorization excludes the use of images/recordings for:

• Commercial sale
• Third-party marketing without additional consent
• Public display without explicit permission

Signatures

Parent/Guardian Signature: _________________ Date: //___

Witness Signature: _______________________ Date: //___

Practice Representative: __________________ Date: //___

A copy of this authorization will be provided upon request.