A photography consent form records a patient’s agreement to clinical photographs, video, or audio recordings: what will be recorded and why, who records it and on what device, and which uses they agree to, from their own record to teaching or publication, each chosen separately. Copy the free form, see a dermatology mole check and a home care pressure injury example, and check what goes in each part.
Blank photography consent form template
FreePHOTOGRAPHY AND RECORDING CONSENT FORM Consent to clinical photographs, video, or audio recordings [Organization name] [Department, address, and phone] THE PATIENT Name: [Full name] Date of birth: [Date] Record number: [Number] Language: [Preferred language, and the interpreter used, or none] WHO IS AGREEING Consent given by: [The patient, a parent or guardian, or a substitute decision-maker] If not the patient: [Name, relationship, and why they are deciding: the patient's age, or a capacity finding, under the rules where you practice] The patient's own view: [For a child or an adult who can't decide: what they said or showed about being recorded, or not applicable] WHAT WILL BE RECORDED Type: [Photographs, video, audio, or more than one] What is in frame: [Body area, lesion, wound, movement, procedure, or the whole consultation] Identifying features: [Face, tattoos, birthmarks, scars, jewelry, a name band, or none in frame] Intimate areas: [None, or which areas and the chaperone present] Others recorded: [Staff, family, or an interpreter who may be seen or heard, and that they agree, or none] Why: [To record the condition, to compare over time, to get a specialist opinion, to assess movement, or for teaching] How often: [Once, at each visit, weekly until healed, or a set number of sessions] Not covered here: audio recorded by an AI scribe to draft visit notes, which has its own consent. WHO RECORDS AND ON WHAT DEVICE Taken by: [Name and role, or the team, such as the home care nurses] Device: [Organization camera, tablet, or phone, or an approved app that saves straight to the record] Personal devices: Not used. Images are not kept on personal phones, in photo libraries, in messaging apps, or in personal cloud storage. HOW THE IMAGES MAY BE USED Mark yes or no for each use. You can agree to some and not others. 1. My health record: [Yes or no] Kept in my record and used for my care. 2. My care team: [Yes or no] Shared with clinicians caring for me, such as [a specialist, a wound clinic, or my usual clinician]. 3. Teaching within [organization name]: [Yes or no] Shown to staff and students for education, [with identifying features removed, or identifiable]. 4. Publication or presentation: [Yes or no] Used outside the organization, in a journal, textbook, or conference, [with identifying features removed, or identifiable]. I want to see the images before they are used: [Yes or no]. 5. Marketing, websites, or social media: Not covered by this form. It needs its own written consent that names the images and the exact use: [Separate consent signed on a date, or not applicable]. STORAGE AND SECURITY Where stored: [The health record, or the organization's approved image system] Who can see them: [The people caring for me, and the uses I marked yes] How long kept: [As long as the law where you practice requires health records to be kept, then securely destroyed] Removing identifying features: [For teaching or publication: face, tattoos, jewelry, labels, and file data such as dates and location removed, and who checks] Teaching or publication copies: [Where they are kept, and when they are deleted] YOUR CHOICES Saying no to any use, or to all of them, will not change your care. You can ask us to stop recording at any time. You can withdraw consent for future use at any time by telling [name or contact]. Images already published or presented can't be recalled. Images taken for your care stay in your health record. Questions: [Who to ask, and their phone or email] CONSENT I have been told what will be recorded and why, who will record it, where it will be kept, and who can see it. I agree only to the uses I marked yes. I can say no, ask for recording to stop, or withdraw my consent for future use, and my care will not change. Consent covers: [This visit only, or a series until a date or event, such as until the wound heals] Patient or person giving consent: [Signature, printed name, relationship if not the patient, and date] Clinician: [Signature, printed name, role, and date] Interpreter: [Signature, name or ID, and date, if one was used] RECORD OF IMAGES TAKEN Taken: [Date, time, number of images or length of recording, body area, and who took them] Saved to: [Where in the record] Consent checked again: [Dates at later sessions, and any change] Withdrawn: [Date, which uses, and who was told, or not applicable]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Dermatology clinic; photos today and a repeat set in 3 months
Leila Haddad, born August 19, 1985, age 41. Record number 3318402. English; no interpreter. Gives her own consent. Works as a nurse in the hospital’s intensive care unit.
Photographs: an overview of her back with a scale sticker beside the mole, to show where it is; a close-up; and a dermoscopic image, taken through a dermatoscope. The mole is on the right upper back: flat, 6 by 5 mm, in two shades of brown. She and her partner think it has darkened over 6 months. Dermoscopy shows a slightly irregular network at one edge and no structures specific to melanoma. Why: to record it today, and to compare the same three images in 3 months. In frame: no face. A small swallow tattoo on her left shoulder blade was framed out of the overview at her request. No intimate areas, and no one else recorded.
Taken by Marco Silva, dermatology nurse, with the clinic’s imaging camera and dermatoscope, which save straight to the image section of her record. No personal phones.
1. Health record: yes. 2. Care team: yes, including the plastic surgery team if the mole needs to come off. 3. Teaching: no. She said: “I work here. I’d rather my colleagues didn’t see my back in a teaching session.” 4. Publication or presentation: no. 5. Marketing: not covered by this form, and not asked.
Stored in her record’s image section, open to the staff caring for her, and kept as long as her health record is kept. Removing identifying features: not needed, since the images stay in the record. Told that saying no to teaching changes nothing about her care, that she can ask to stop at any time, and that she can withdraw consent for future photos by telling the clinic; the images already taken stay in her record. She asked whether her photos could end up in a teaching set by mistake. Explained that the image system marks them record only, and the teaching team uses only images with teaching consent.
Dr. Naomi Clarke, dermatologist, offered removal now or short-term monitoring: the same three images repeated in 3 months, and removal if the mole has changed in size, shape, color, or structure. Leila chose monitoring. Consent covers today’s images and the repeat set in 3 months. Signed by Leila Haddad and Marco Silva, November 9, 2026, 10:15 a.m.
November 9, 2026, 10:20 a.m.: 3 images of the right upper back, taken by Marco Silva and saved to her record. Next set due in February 2027, in the same position, lighting, and scale. Decision: photos for her record and care team only; teaching and publication declined.
Home care nursing visit; a 67-year-old with a pressure injury over the sacrum
Raymond Fortier, born March 3, 1959, age 67. Home care record 77-20419. Home for 10 days after 4 weeks in hospital with a stroke, which left weakness on his left side; his speech and understanding are unaffected. Uses a wheelchair and a pressure-relieving mattress. Type 2 diabetes. Gives his own consent, with no concerns about his capacity for this decision. His wife, Diane, was there at his request.
Photographs of a stage 3 pressure injury over the sacrum, first noted in hospital: 4.0 by 3.2 cm and 0.6 cm deep at today’s visit. In frame: the wound and a paper measuring guide only, with his record number and the date written on the guide. He lies on his right side, with a drape over his buttocks and thighs. No face or other identifying features. Why: to track healing week by week, beside the measurements in his wound care note, and so the agency’s wound specialist nurse can see the wound between her visits. How often: weekly, at the Monday visit, until it heals.
Taken by the home care nurses who visit him, with the agency’s tablets and its wound imaging app, which saves each photo straight to his home care record and keeps no copy on the tablet. Diane asked if she could text photos to the nurses between visits. Explained that the agency doesn’t accept photos by text, and that she should call the nursing line if the wound looks bigger or redder, smells, or he has a fever, and a nurse will come.
1. Health record: yes. 2. Care team: yes: the agency’s wound specialist nurse, his family doctor, Dr. Samuel Park, and the hospital wound clinic if he’s referred. 3. Teaching within the agency: yes, with identifying features removed, for wound care sessions for new nurses. 4. Publication or presentation: no. The wound specialist nurse asked whether his photos could go in a conference poster on wound healing at home. He said: “The nurses can learn from it. I don’t want it going further than that.” 5. Marketing: not covered by this form; no.
Stored in his home care record, open to the staff caring for him, and kept as long as the agency must keep health records where it operates. Teaching copies: chosen by the wound specialist nurse after the wound heals, cropped to remove the guide with his record number, with the file data removed, and checked by a second nurse before use. Kept in the agency’s education folder, and deleted after 5 years, or sooner if he withdraws.
Told that saying no to any use won’t change his care, that he can ask a nurse to skip the photos at any visit, and that he can withdraw consent for future use by calling the agency; teaching copies would then be deleted, but the photos in his record stay. Consent covers weekly photos until the wound heals, and nurses check at each visit that he’s still happy to go ahead. Signed by Raymond Fortier and Aisha Bello, RN, at his home on November 9, 2026, 9:40 a.m.
November 9, 2026, 9:50 a.m.: 2 photos of the sacral wound, taken by Aisha Bello, RN, and saved to his record. Each weekly set logged with the date, and a line that he agreed again. Decision: weekly photos for his record and care team, and for teaching within the agency with identifying features removed; publication declined.
Who the patient is, and who makes the choice: the patient, or a parent, guardian, or substitute decision-maker when the patient can’t.
Avoid: Assuming the person who consents to treatment can agree to every use. For uses beyond the patient’s own care, such as teaching or publication, wait until the patient can decide if you can, and otherwise follow your local rules.
Exactly what the camera or microphone will capture, in words the patient would use, and what it’s for.
Avoid: “Clinical photography as required.” Name the body area and how many sessions. A new area or a new reason needs a new conversation.
Who takes the images, and on what. Most organizations require their own devices, or an approved app that saves straight to the record, and don’t allow personal phones.
Avoid: A quick photo on your own phone, to upload later. Phones back up to personal cloud storage and share photos with other apps, so a copy can outlive the upload.
Each use is a separate choice. A patient who agrees to photos for their record hasn’t agreed to teaching, and agreeing to teaching isn’t agreeing to publication.
Avoid: One signature under “photos may be used for care, teaching, and publication.” Ask about each use, record each answer, and accept a no to some.
Where the images live, who can open them, how long they’re kept, and what removing identifying features means for this patient.
Avoid: A black bar over the eyes. It doesn’t make a person anonymous. Crop to the area that matters, and ask whether the patient, or someone who knows them, could still recognize the image.
Saying no must be easy, and it must not change the patient’s care. Tell them what withdrawing consent can and can’t undo.
Avoid: Promising to delete images taken for care if the patient changes their mind. They’re part of the record. Promise what you can do: no new images, and no further teaching or publication.
The signatures, how long the consent lasts, and a log of each set of images, so anyone can see what was taken under this consent.
Avoid: Leaning on an old consent. A series consent ends with its date or event, such as the wound healing; a new problem or a new episode needs a new form.
Consent for the record isn’t consent for teaching, and teaching isn’t publication. Ask about each use, and accept a no to some of them.
Even if you upload the photo and delete it, a copy may already be in a cloud backup or a shared album. Use an organization device, or an approved app that saves straight to the record.
A tattoo, a birthmark, a ring, a name band in the corner, or the date and location in the file can identify someone. Check the whole image and its file data before it leaves the record.
Before-and-after photos on a website or social media need their own written consent that names the images and the use. A clinical photography consent doesn’t cover them.
Tell the patient exactly what will be in frame, offer a chaperone, and record who was there. Take only what the care needs, and keep the images in the record.
Vero Scribe drafts the consent form in your template from the conversation, with the patient’s consent, or from your dictation: what will be recorded and why, the device, and each use the patient agreed to or declined. You review and edit every section, then copy it into your record or export it to Word or PDF for signing. Vero works in 60+ languages.
Who the patient is and who is agreeing; what will be recorded, why, and how often; who takes the images and on what device; each use as a separate yes or no: the patient’s record, their care team, teaching, and publication, with marketing left to its own consent; where the images are stored, who can see them, and how long they’re kept; how identifying features are removed; the right to say no and to withdraw for future use; and signatures, with a log of each set of images taken.
Yes. Clinical images are health information, and taking them is part of care, so they need the patient’s agreement. For images that stay in the record, many organizations accept verbal consent noted in the chart. For teaching, publication, identifiable images, and intimate areas, most ask for a signed form. If a patient can’t consent, as in an emergency, take only the images their care needs, and ask about any other use once they can decide. Follow your organization’s policy and the law where you practice.
Consent to record video of a patient: a consultation recorded for training or supervision, a gait or movement assessment, movements such as tics or seizures recorded to help with diagnosis, or a procedure. The form works the same way as for photos. Name anyone else who will be on camera, such as staff, family, or an interpreter, and get their agreement too. Audio recorded by an AI scribe to draft notes has its own consent.
Yes, at any time, for future use. Stop taking new images, take theirs out of teaching sets, and don’t submit them for publication. Images already published or shown at a conference can’t be recalled, so tell the patient that before they agree. Images taken for their care stay in the record, kept like the rest of it. Note the date, which uses were withdrawn, and who was told.
Usually, yes: a parent or legal guardian consents for a child who can’t decide for themselves. Explain it to the child too, and take their wishes seriously, especially for uses beyond their own care. A young person who understands the choice may be able to consent on their own where the law allows. For teaching or publication, think about how the child may feel about the images as an adult, and keep identifiable use to a minimum. Follow your local rules.
Only if your organization’s policy allows it, and then only with an approved app that saves the image straight to the record and leaves no copy on the phone. Never save clinical images to the phone’s photo library, or send them by text, a messaging app, or personal email. If your organization doesn’t allow personal phones, use its cameras or tablets.
No one, including the patient or someone who knows them, could tell who it is. Crop to the area that matters, and remove or cover the face, tattoos, birthmarks, distinctive scars, jewelry, name bands, labels with names or record numbers, and anything telling in the background. Strip file data such as the date, time, and location. A black bar over the eyes isn’t enough. If a feature can’t be removed, such as a condition on the face, treat the image as identifiable and get consent for that.
Yes. Copy it, or download it as a Word or text file. No account needed.
A patient leaving or refusing care: the recommendation, capacity, risks in plain words, alternatives, signature or refusal to sign, and the care still given.
A patient’s authorization to release health information: who sends and receives it, what goes, sensitive records, purpose, end date, rights, and the release log.
Consent to a procedure or treatment: benefits, risks, alternatives, capacity, signatures, and the discussion note.
A parent names another adult to consent to their child’s care: dates, what it covers, health details, and signatures.
Screening questions, consent or declination, and a record of each dose: lot, expiry, site, observation, and the next dose due.
Patient-specific consent forms from your clinic’s own templates.
Morphology, body site, and follow-up detail, drafted for your review.
Wound assessments tracked across visits, drafted for your review.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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