Medical Photography Consent Form

Name*

First Last

Date of Birth*

Consent*

I agree that the images may be:

… placed in my medical record for future treatment*

... electronically emailed to my treating health professional*

... used by health professionals for education and training*

... used in paper or electronic health publications*

... used in commercial broadcast*

... used in marketing materials*

Consent*

By signing below, I confirm that I understand this consent form.

Date*

Signature of Patient/Parent or Guardian:*

Date*

Signature of Doctor/Health Professional/Staff:*