PHOTOGRAPHY 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]