Know the boundaries
Not for: Marketing, media access, research publication, teaching outside the approved care workflow, or an all-purpose HIPAA authorization.
Source-checked template, version 2.0, September 21, 2026. Practice review and adaptation are required before use. No independent clinician or attorney approval is claimed. Adult patient self-consent only; use a separately reviewed process for minors or representatives.
Inside the template
Two clean, unbranded patient-facing pages: the relevant discussion, specific choices and completion fields, and the patient decision with signatures. The PDF includes fillable fields and selection controls where applicable. Use the Word version to adapt the language. Sources and practice guidance stay on this page. Typed fields are not a verified electronic-signature service.
Actual sample page · Open to enlarge · Full editable files available below
Prepare your practice version
- Name the body area and clinical purpose before capture.
- Explain who captures the images and where they are stored.
- Use approved equipment and transfer workflows; keep images out of personal galleries.
- Route any proposed public use through a separate authorization review.
Public text preview
Language for the conversation
Record use
The practice has explained where the images are stored and who may access them for care. Images will be handled under applicable law and the practice's privacy policies. This form does not replace the notice of privacy practices.
No public permission
This form gives no permission for advertising, public websites, social media, testimonials, outside media access or unrelated publication. Those uses need separate review and any required authorization.
Choice and retention
I may ask questions, pause photography or decline further capture. The clinician will explain alternatives and any effect on assessment or treatment. Existing clinical images may need to remain in the record under applicable retention requirements.
Details to complete before signing
- Practice name
- Visit / discussion date
- Patient full name
- Date of birth
- Clinician / photographer
- Photograph date or visit covered
- Body areas and image types to be captured
- Clinical purpose and how the images will support care
- Preferences, limits, questions and agreed response
- Approved storage system and care-team access explained to the patient
- Alternative assessment / documentation options and any effect of declining
- Patient signature
- Date / time
- Clinician / practice representative name
- Signature / date
- Interpreter name / ID if used
- Language
- Discussion notes / reasons for limits or alternative plan
- Copy provided to patient by
- Date / method
Common questions
Does this allow before-and-after photos on Instagram?
No. This template explicitly excludes public promotion. Use a separately reviewed marketing authorization for the chosen images and channels.
Is this a universal HIPAA requirement for all clinical photos?
No. This is a suggested documentation workflow. The legal basis and consent requirements depend on the use, jurisdiction and practice; the template does not declare a universal photography rule.