(03) 7067 9688 [email protected]

Photo Consent Form (ALL patients to complete)

PHOTOGRAPHY CONSENT

For almost all patients, clinical photography will be taken to assist in your care. These become part of your confidential medical records. We also would like to ask you for permission to reference these photos for educational purposes in addition to their use as part of your medical care. Names are not used, and identifying factors are masked when requested.

These photos are very helpful in teaching other doctors and helping other patients make an informed decision about their surgery. Do you consent to your before and after clinical photos being used:

    For the purpose of teaching other health professionals such as doctors, nurses and associated students?
    YesNo

    In scientific publications e.g. articles in medical journals?
    YesNo

    To educate other patients, within our clinics?
    YesNo

    To educate patients on our website
    YesNo

    To educate patients on our social media accounts
    YesNo

    To educate patients on our email newsletter
    YesNo

    If you have ticked yes to any of the above and have any special requests with regards to how your photos are displayed or used, please list them below:

    These photos are stored in a secure server in compliance with the Australian Privacy Principles.

    They will be accessed by clinic staff and will not be sold or transferred to any other entity for purposes that have not been agreed to.

    Declaration: I grant permission for photographs of me to be used in the formats indicated above. I am at least 18 years of age, have read and understand the foregoing statement, have not been offered inducements to provide permission, and am competent to execute this agreement.

    Patient Name:

    Patient Signature:

    Date:

    Address

    The Avenue Private Hospital
    40 The Avenue
    Windsor
    Melbourne
    3181

    Contact

    Contact Number: (03) 7067 9688
    Fax Number: (03) 7046 6822
    Secure messaging for health professionals:
    Healthlink EDI: drfotios

    hours

    Monday - Friday 9am - 6pm

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