Clinical Photography Consent Form

Patient Name: Date of Birth: Medical Record Number:

Consent

I hereby consent to the taking of clinical photographs for the purposes of diagnosis, treatment, teaching, or publication as deemed appropriate by my healthcare provider. I understand that my identity will be protected unless I have authorized otherwise.

Consent for use in my medical records and clinical care Consent for use in professional teaching and presentations Consent for publication in journals or medical literature I consent to my identity being revealed

Restrictions or Notes:

Patient/Guardian Signature:

Date:

Witness Signature:

Date: