Podiatry Photo Consent Form
Please complete this form to provide permission for clinical photos related to your foot and ankle care and to note any limits on their use.
Patient Information
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Patient ID / Chart Number
Clinic / Visit Details
Clinic / Practice Name
*
Treating Podiatrist / Clinician Name
*
Visit Date
*
-
Month
-
Day
Year
Date
Reason for Visit / Condition Being Treated
*
Photo Consent Scope
Photo Use Scope
*
Treatment documentation only
Treatment documentation and staff training
Treatment documentation, staff training, and educational materials
Do not consent to photo use
Acknowledgment
*
I agree to the stated photo use scope
Photo Use Preferences
Do you permit identifiable images to be used?
*
Yes
No
Only for clinical recordkeeping
Use restrictions
No public website
No social media
No printed marketing
No internal training
Other
Allow before-and-after comparison images?
Yes
No
Authorization, Signature, and Date
Patient or Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Patient (if not the patient)
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: