Patient Photography Consent

Your Consent

1. Photographs can help document your care and teach others. Please tell us whether you agree to be photographed and how the images may be used.

2. Do you agree to be photographed as part of your treatment?

   Choose one:

   • Yes
   • No

3. May your photographs be used to train doctors, nurses and other health professionals?

   Condition: Asked when the patient agreed to be photographed

   Choose one:

   • Yes
   • No

4. May your photographs appear in scientific journals or books, with anything that could identify you removed?

   Condition: Asked when the patient agreed to be photographed

   Choose one:

   • Yes
   • No

Storage and Use of Photographs

Condition: Asked when the patient agreed to be photographed

1. Please confirm whether each statement is true for you.

   • I understand my photographs will be kept securely.
   • I know I can withdraw my consent whenever I choose.
   • I understand the practice's photography policy.
   • I am comfortable with my photographs helping to improve care for other patients.

   For each row: choose one:

   • Yes
   • Not sure
   • No

Concerns and Suggestions

1. Do you have any concerns about how your photographs may be used?

   Choose one:

   • Yes
   • No

2. Please tell us about your concerns.

   Condition: Shown when the patient has concerns

   Open answer

3. How could we make asking for photography consent clearer or easier? (optional)

   Open answer