Patient Media Usage Consent Form
Patient Information
Full Name
Date of Birth
Contact Number
Consent Details
I authorize the use of the following media (check all that apply):
Photograph
Video
Audio Recording
Purpose of Use
I give my consent for media use in the following (check all that apply):
Website
Social Media
Printed Materials
Other
Terms & Conditions
Signature
Patient/Guardian Signature
Date
If signed by guardian, state relationship to patient