Clinical Photography Consent Form

Please complete our Clinical Photography Consent Form.

Description of recording

Date of visual recording

Consent to use the visual recording detailed is requested for:*

Clinical research

Presentation for educational use to healthcare staff and students.

Presentation to the general public.

Exhibition materials (e.g. clinical poster)

Patient education (e.g. to show patients undergoing the same treatment)

Publication in (title must be provided)

Other (details of intended use)

Publication

Other

Requestors Name: Robert Mast

I have explained the nature and purpose of the secondary use to the patient

Signature of Requestor

Patient Details:

I understand the secondary use details on the form and give consent: Your personal data will only be used for the purposes detailed. If at anytime you do not want your personal data to be used for this purpose and wish to withdraw your consent, please contact us at: Info@sonoscope.co.uk

Name:

First

Last

Address

Date of birth

Signature of Patient

Clinical Photography Consent Form

Requestors Name: Robert Mast

Patient Details:

Clinic contact