Know the boundaries
Not for: Marketing, media access, research publication, teaching outside the approved care workflow, or an all-purpose HIPAA authorization.
Source-checked educational draft, version 1.0, September 20, 2026. Not reviewed or approved by an attorney or clinician. A qualified professional must adapt and approve it for the practice, jurisdiction, patient and actual service before use. A signature does not replace an informed discussion. Adult templates only; not a minor or proxy-consent workflow.
Inside the template
Five pages: practice preparation, patient discussion, two completion pages, and an implementation/source appendix. The PDF has fillable text fields; use the Word version to revise the language. 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
Purpose and scope
I agree to the clinical photographs described below for documenting and discussing my care. The practice has explained the areas to be photographed and why these images are useful. I can ask questions or ask the photographer to pause.
Storage and access
The practice has explained where the images become part of my record and which care-team roles may access them. Clinical record handling follows applicable law and practice policies. This form does not replace the notice of privacy practices or create a separate permission for every otherwise lawful record use.
No public permission
I am not giving permission through this form for advertising, social media, public websites, testimonials or outside media access. A separate review and, where required, authorization is needed for those uses.
Details to complete before signing
- Patient name
- Practice and clinician / photographer
- Body areas and image types
- Clinical purpose
- Approved storage system / access roles explained
- Patient preferences, limits or questions
- Alternatives and consequences discussed if photography declined
- Patient signature and date
- Clinician signature and date
- Copy supplied: 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.