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Photo & Video Consent Form
Consent

Photo & Video Consent Form

2 pages•10 fields•HIPAA-ready
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Photo & Video Consent Form
Patient Name
Date of Birth
Date of Consent
Provider / Photographer Name
Body Area to be Photographed
Purpose of Photography/Video
Usage Authorization (Medical/Education/Marketing)
Storage & Retention Acknowledgment
Right to Revoke Consent
I agree to the terms above
Sign here
Patient Signature
Sign here
Submit
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The Photo & Video Consent Form authorizes healthcare providers to capture, store, and use clinical photographs or video recordings of patients. This form is essential for practices that document clinical findings photographically (dermatology, plastic surgery, wound care), use before-and-after photos for treatment planning, or create educational or marketing content featuring patients.

The form clearly distinguishes between different usage categories: clinical documentation for the medical record, educational use for staff training, publication in medical journals or presentations, and marketing or website use. Patients can consent to some categories while declining others -- for example, allowing clinical documentation but not marketing use.

Storage and retention policies are documented, including where photos are stored, how they are secured, and how long they are kept. The patient's right to revoke consent at any time is clearly stated, along with the process for requesting deletion. For minors, parent or guardian consent is required. This template meets the requirements of both HIPAA (as clinical photography constitutes PHI) and state-specific medical photography consent laws.

What's included

  • Patient identification with date of birth
  • Date of consent documentation
  • Provider and photographer identification
  • Body area specification for photography
  • Purpose specification for photography/video
  • Granular usage authorization by category
  • Storage, security, and retention policies
  • Right to revoke consent at any time
  • Minor consent provisions
  • HIPAA-compliant photo handling acknowledgment
  • E-signature capture

Who uses this template

  • Dermatology and plastic surgery practices
  • Wound care and before/after documentation
  • Healthcare marketing departments
  • Medical education and case presentations

All form fields

10 fields across 2 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Date of ConsentDate
Provider / Photographer NameText
Body Area to be PhotographedText
Purpose of Photography/VideoCheckbox
Usage Authorization (Medical/Education/Marketing)Checkbox
Storage & Retention AcknowledgmentCheckbox
Right to Revoke ConsentConsent Agreement
Patient SignatureE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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