Image Consent Form

  Date:

______________________________________________________________

Patient Name:

______________________________________________________________

Procedure:

______________________________________________________________

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:

Yes

No

1

I am happy for my before and after photographs to be

shown to patients considering treatment.

2

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:_____________