Surgical Photography and Video Recording Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: _________ Date: _____________________

Authorization

I, ________________________________, hereby authorize Dr. _________________ and [Hospital/Practice Name] to take, produce, and use clinical photographs, videos, and/or digital images of my surgical procedure(s), medical condition(s), and treatment(s).

Permitted Uses

I understand these images may be used for the following purposes:

• Medical documentation and inclusion in my health record
• Educational purposes, including medical teaching
• Scientific publications and medical presentations
• Quality assurance and surgical planning

Privacy Protection

• All images will be stored securely following HIPAA guidelines
• Reasonable efforts will be made to protect my privacy and identity
• Any identifying features not relevant to the medical purpose may be obscured

Terms and Conditions

1. I understand I have the right to revoke this authorization in writing at any time
2. I waive any right to royalties or compensation for the use of these images
3. I understand refusing to sign this form will not affect my medical treatment
4. This authorization expires in 50 years unless otherwise specified: ____________

Signatures

Patient/Legal Guardian: _________________________ Date: __________

Witness: _____________________________________ Date: __________

Physician: ___________________________________ Date: __________

This form complies with HIPAA requirements and medical documentation standards.