Photography and Video Authorization Form for Plastic Surgery

I, [Patient Name] ______________________, hereby authorize Dr. [Surgeon Name] ______________________ and [Practice Name] ______________________ to take photographs, slides, and/or videos of my face, body, and/or affected treatment areas.

Purpose of Photography/Videography

• Pre-operative and post-operative documentation
• Surgical planning and assessment
• Medical education and training
• Professional medical presentations
• Marketing and advertising (if authorized below)

Authorization Details

Medical Usage

I understand and consent that these images/videos may be used for:

• Clinical documentation in my medical record
• Surgical planning and consultation
• Communication with other healthcare providers
• Quality assurance purposes

Educational Usage (Initial one)

_____ I AUTHORIZE the use of my images/videos for medical education and training. _____ I DO NOT authorize the use of my images/videos for education and training.

Marketing Usage (Initial one)

_____ I AUTHORIZE the use of my images/videos for marketing purposes, including:

• Practice website
• Social media
• Promotional materials
• Before/after galleries _____ I DO NOT authorize the use of my images/videos for marketing purposes.

Understanding and Agreement

1. I understand that I will not receive payment for any use of these images/videos
2. All images will be taken with appropriate draping and respect for privacy
3. Identifying features will be concealed when possible unless specifically authorized
4. I may revoke this authorization in writing at any time

Signatures

Patient Signature: ______________________ Date: __________

Witness Signature: ______________________ Date: __________

Physician Signature: ______________________ Date: __________