Know the boundaries
Not for: Clinical photography alone, treatment consent, minors, or a blanket release of all future images.
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
- Select the exact before-and-after images before asking for a signature.
- Specify websites, social accounts, print uses and any outside agencies that will receive the images.
- Document whether the face, name, voice or other identifying details may be shown.
- Check the expiration and revocation status before every new publication.
Public text preview
Language for the conversation
What I authorize
I authorize the practice or person identified below to use and disclose only the selected images and related identifying details, to the recipients and for the purposes written below. Unselected images and other medical records are not included. No permission is implied for additional channels.
Publication choices
Describe each approved channel and its audience. Use an attached image/contact sheet where helpful. Cropping and layout changes must stay within the agreed scope; an altered image must not misrepresent the result. This authorization is separate from my care decision.
My rights
Signing is voluntary. Refusing will not affect treatment, payment, health-plan enrollment or eligibility for benefits. I may revoke this authorization in writing using the practice contact below, except for action already taken in reliance on it. Recipients may share the disclosed information again, and it may no longer be protected by HIPAA. Public copies may be impossible to retrieve. I will receive a copy of this signed authorization.
Details to complete before signing
- Patient name
- Practice / person authorized to disclose
- Specific photos or media IDs and dates (attach selected set)
- Permitted identifying details (e.g., first name, face, treatment)
- Named recipients / recipient classes and specific channels
- Purpose of each selected use
- Expiration date or event related to this use
- Written revocation contact and mailing / email address
- Third-party remuneration to practice: none / describe if applicable
- Patient signature (sign after review) and date
- Copy supplied to patient: date / method
Common questions
Is a before-and-after photo release the same as treatment consent?
No. Use a separate publication authorization. Consent to treatment or taking a clinical image does not by itself specify permission to advertise with that image.
Can the patient withdraw permission?
The template provides a written revocation route and explains reliance on prior authorization. Build a workflow to stop new uses and assess existing placements; do not promise recovery of public copies.