Surgical Procedure Image Use Consent

I hereby authorize the use of images or photographs of myself taken before, during, and after my surgical procedure for the purposes of education, publication, medical records, or presentations. I understand that my identity will be protected as much as possible, and that no identifying information will be included.

Purpose of Image Use

Medical education and training
Scientific publication or presentations
Medical records documentation
Other professional uses

I acknowledge that these images may be used in various media, including print, electronic, and online formats. I understand that my consent is voluntary and that I may withdraw it at any time by notifying my surgical provider in writing.

Patient Information

Patient Name: Date of Birth: Surgical Procedure:

Date:

Patient Signature:

Witness Name: Witness Signature: Date: