Sample Consent for Photography/Videotaping (for Media or Educational Purposes)

Patient’s Name:

Identification Number:

I hereby give my consent to have photographs, videotaped images, or other images made of myself or my family member and/or consent to interviews with a member of the news media or a representative of (name of organization). I understand and agree that these images may be used by the news media or by (name of organization) for the purpose outlined below:

Signature of Patient or Legal Representative Date Signature of Witness Date

Note: This sample form is provided for discussion purposes only. It is not intended for use without the advice of legal counsel.

Source: AHIMA Practice Brief, "Patient Photography, Videotaping, and Imaging" (Updated June 2001)