Physical Therapy Photo and Video Release Authorization Form

Patient Information

Name: ________________________________
Date of Birth: __________________________
Phone: ________________________________

Authorization

I, _________________________, hereby authorize [PRACTICE NAME] and its physical therapists, staff, and representatives to:

• Take photographs, videos, and/or audio recordings of me or my dependent
• Use these media materials for the following purposes:
  • Clinical documentation
  • Treatment planning and monitoring
  • Educational training
  • Professional presentations
  • Marketing materials (optional)

Terms and Conditions

1. I understand that these media materials will be used for legitimate medical, educational, and/or business purposes.
2. I understand that I have the right to revoke this authorization at any time by submitting a written request.
3. I understand that I will not receive compensation for the use of these materials.
4. I understand that all media will be stored securely in accordance with HIPAA regulations.

Specific Permissions (check all that apply)

□ Clinical documentation only
□ Internal staff education
□ Professional conference presentations
□ Marketing materials and social media
□ Other: ____________________________

Signature

Patient/Guardian Signature: _____________________
Date: _______________

Witness Signature: ____________________________
Date: _______________

Revocation

This authorization will remain in effect until revoked in writing.

Form ID: PT-VR-[DATE]