Sample Consent for Photography/Videotaping (for Media or Educational Purposes)
| Patient’s Name: |
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| Identification Number: |
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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:
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| 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) |