Image Consent Form






Patient Name:






This form enables you to decide what happens to your photos after they have been taken.



As you know, pre-and post- treatment images are always recorded and handled in accordance


with data protection principles.  As cosmetic treatments are a very visual speciality it is a


requirement that all of our patients have their photographs taken before and after


treatment.  These photographs are stored securely and we adhere to a strict policy of


controlling access to your photographs.


Some people prefer their photographs to be kept private and others are happy for anonymous


versions to be shared with other people considering cosmetic treatments.


We will respect your wishes and would be grateful if you could answer the following questions


regarding how you would like your photographs to be used.


Please tick yes or no to the following questions:







I am happy for my before and after photographs to be


shown to patients considering treatment.







I am happy for my photographs to be shown online








I ____________________________________________________consent to the choices I have


chosen above and confirm that these images were taken with my knowledge.


All Patient details will remain anonymous at all times.


Patient Signature:______________________________________   Date: ____________________________


Photographer Signature:_____________________________Date:___________________Time:_____________