Know the boundaries
Not for: Clinical photography alone, treatment consent, minors, or a blanket release of all future images.
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
- 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
Voluntary choice
I can refuse this authorization without affecting my treatment, payment, health-plan enrollment or eligibility for benefits.
Written revocation
I may revoke this authorization by writing to the contact below. Revocation will not undo action already taken in reliance on my authorization. The practice must assess and stop future uses that are no longer authorized.
Public disclosure
Recipients may share my information again, and HIPAA may no longer protect it. Online material can be copied or archived beyond the practice's control; complete removal cannot be promised. I may be recognizable even without my name.
Details to complete before signing
- Practice name
- Visit / discussion date
- Patient full name
- Date of birth
- Exact image / video IDs, capture dates and attachment reference
- Practice or person authorized to use / disclose
- Treatment information allowed in captions
- Specific websites, accounts, other channels and recipients / recipient classes
- Purpose of each selected use and any limits
- Patient compensation (none / detail)
- Third-party payment to practice (none / detail)
- Written revocation contact and postal or email address
- Expiration date or event related to this use
- Patient initials
- Patient signature
- Date / time
- Clinician / practice representative name
- Signature / date
- Interpreter name / ID if used
- Language
- Copy provided to patient by
- 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.